Protrusive Dental Podcast

‘Easy Dentistry on Difficult Patients is still Difficult’ – Dr Lincoln Harris Patients with small mouth opening can be a huge pain in the back for Dentists – but did you know there are ways we can significantly improve their mouth opening through physiotherapy? https://youtu.be/v_u9sBAGliU Watch GF020 on Youtube In this episode I’m joined by Dr. Tzvika Greenbaum, a specialist TMJ physiotherapist who’s here to spill the beans on his journey from headaches to jawaches. We bring to light the jaw-dropping collaboration between dentists and physiotherapists, making dental treatment easier for both you and your patients. Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode:00:00 Intro01:02 Dr. Tzvika Greenbaum03:39 Dentistry meets physiotherapy09:33 Range of movement10:23 Asymmetry11:20 Prevention12:20 Advice to dentists14:34 Stretching16:17 The dental gym16:57 Sleep bruxists vs. awake bruxists19:28 Reducing sleep bruxism20:52 Obstructive sleep apnoea22:03 Statistics and diagnostic criteria25:16 At-home exercises27:20 Pain and discomfort28:39 Rehabilitation30:14 When to involve a physiotherapist31:12 Expected results32:21 Screening34:15 Dr. Greenbaum’s event39:04 Outro Dr. Greenbaum’s upcoming course: protrusive.co.uk/greenbaum If you liked this episode, you will also like 3 Simple TMD Exercises Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month? Click below for full episode transcript: Jaz's Introduction: One of my mentors, Dr. Lincoln Harris, once taught me that easy dentistry on a difficult patient is still difficult, and nothing makes our dentistry more difficult than that patient who just can't open, or the patient that keeps closing their mouth. Like, it's impossible to do high quality work in that kind of a patient. Jaz’s Introduction:Hello, Protruserati. I’m Jaz Gulati, and in this Group Function where we just focus on one theme, today’s big topic is “Help! My patient Can’t Open Their Mouth!” And you’ll be amazed with some physio with some exercises with some training if you like your patient can actually open significantly more allowing you to do better dentistry and allowing the patient to get better outcomes. We’re joined today by our first ever Israeli guest Dr. Greenbaum who is a physiotherapist who specialized in the area of TMD and he’ll be coming soon to the UK. So I thought ahead of his visit, let’s talk about a really important topic that I think is going to help you guys in the real world where our patients are struggling to keep their mouth open. What causes this and how can we get involved either just by yourself or working in tandem with a physiotherapist? Let’s join the main episode now and I’ll catch you in the outro. Main Episode:Dr. Greenbaum, welcome to the Protrusive Dental Podcast. How are you? [Tzvika]Hey, hi Jaz. I’m very well. Thank you very much. And thank you for inviting me to speak about my favorite topic, which is Rehabilitation of Patients with Temporomandibular Disorders. [Jaz]It’s great to be able to help our patients in pain. And this is exactly what it’s about, pain and discomfort. And I’m going to really try and extract all the knowledge and experience that you have. But just share with the Protruserati listening right now, what is your background? How did you niche into rehabilitation of temporomandibular disorders and psychogenic and in that area? [Tzvika]Well, my bachelor’s degree was back in 2004 in Haifa University in Israel. And after that, I headed up to Australia, South Australia to learn a master’s degree in musculoskeletal and sports physiotherapy and a very well-known degree. But in that degree, I started to get into the topic of cervical spine. Upper cervical spine rehabilitation of patients with headaches. It was a new thing for physiotherapists to rehabilitate patients with cervicogenic headaches. And when I came back to Israel after the Masters, I started to see many patients with headaches. And then I realized that many of them are complaining on temporomandibular disorders. Back then I didn’t know exactly what, how to define it, but it was clicks, lockings, pains, bruxism, all kinds of complaints classically involving the masticatory system. And then I’ve realized that there is a topic that is very relevant to my patients, to a majority of my patients, that I don’t know enough. And that was the trigger to start the PhD project in Tel Aviv University back in 2012 or 2013. And there was a professor, Professor Winocur in Tel Aviv University that was actually looking for the physiotherapist to join his team to research the involvement of cervical spine in patients with TMD and that was an excellent match because I could learn from the dentists about our facial pain specialist basically about temporomandibular disorder, and I could share my knowledge about cervical spine with them. So that was a five years of ongoing research project where I was assessing patients with temporomandibular disorders for cervical spine involvement impairments and all kinds of deficits. And during that time, I had the chance to learn about the connections between cervical spine and temporomandibular disorder. And that was my way to that amazing and interesting clinical world. [Jaz]So the work you do now, how much of that is clinical? How much of that is alongside dentists and going on from that, what is the best way that dentists and physios can work together? [Tzvika]One of the main problems in the physiotherapy clinic is that according to the epidemiological findings data, we need to see much more temporomandibular disorder patients, but actually we don’t see them so much. So, there is a big gap between the needs, the demand for patients with TMD and the match to rehabilitation, to musculoskeletal rehabilitation. I think dentists are the best professionals to close these gaps because dentists do see patients with TMD how they see them because they ask their patients to open the mouth. And when you need to open the mouth, that would be the best screening for temporomandibular disorders, even without diagnosing the exact specific diagnosis. But you understand that there is something with the masticatory system, something with the TMJ, and that would be an excellent trigger to refer the patients to the appropriate physiotherapy. So, we see that in different countries that I teach, such as Belgium, for example, I’ve been teaching in Belgium since 2017. And back then, six years ago, the physios did not know what is temporomandibular disorder? How can they get these patients? And while training physiotherapists and also training them to contact dentists, they started to get more and more referrals. And now when I come to Belgium, to Brussels and to Leuven and to Ghent, they keep telling, they tell me all the time that it’s an excellent cooperation because they get, the dentists were looking for the clinicians that can help the patients and the physios were looking for the clinicians that can refer them to patients. So that’s an excellent match between the diagnosis and the referral. And the rehabilitation, practitioner. [Jaz]I totally agree. And with my management of temporomandibular disorders in practice, I don’t think I can get the results without the physio that I use. So hopefully she’ll be joining us when you are visiting the UK in December, Krina Panchal be joining us. I’ve told her all about you. So, she’s excited to learn from you. And then, she’s learned from Rocobado and all these people around the world because just like you said, physios, it’s in the UK. And now you said Belgium as well when they come out of physio school. They’d learn from like the neck downwards, right? They don’t learn about the TMJ, which is just a real loss. But I can see from their perspective, you mentioned that there is a disparity in terms of how many patients should be seeking care from physios compared to what they are. And I think dentists are indeed the link we should be recognizing that physios are in a great position, those who are trained in it are in a great position to help our patients, and we’re going to get better results, patients being more comfortable, less discomfort, better mouth opening, all those things that we want from our patients when you work with a physio. So, yeah, I strongly believe there should be a synergy between dentists and physios. And you told me recently before we hit the record button that you were in Hong Kong and a lot of the delegates, I attended weren’t just physios or healthcare professionals, there were dentists as well, which I think is amazing. I think we can learn so much from each other by attending sort of each other’s sort of educational circles. What kind of things were the dentists in Hong Kong interested to learn about from you? [Tzvika]I think there were two main things for them is one is to understand the specific diagnosis of patients with temporomandibular disorders, not just to know something is wrong with that system. But to understand exactly based on the available evidence, yeah, the body of knowledge that we have, what is the specific diagnosis? And secondly, what can physiotherapists offer patients with TMD? So, what can we actually offer? And what is the prognosis? How to cooperate with the physical therapist? So, these were two main things and it was very interesting because in the first day, it was a day for more for the diagnostic component. They were really up to it and wanting to understand everything and be part of doing that. And in the second day, they were just observing the physiotherapist, just mainly observing how physios can actually approach with the hands on. We had some case studies there, so they were impressed by the ability of the physiotherapist to improve range of motion very quickly as to stretch muscles to understand the connections to the neck, to the cervical spine. So that was very nice to see that there in the first day, they were the one to lead this circle or this combination of cooperation. And the second day they were just observing and really interested in how the other profession is treating, is rehabilitating the patients. Yeah, so in Hong Kong, it was a very interesting cooperation because the course is divided into two main topics. The first day is more about diagnostics and the second day is more about rehabilitation. So the cooperation was very nice to see that in the first day, the dentists were the professionals to lead the day, to be part of the diagnostic seeking to the diagnostic criteria, understand the specific diagnostic differences. And in the second day, they were more watching the physiotherapist in action, the ability of the physiotherapist to improve the range of motion of their patients of the case studies that we had in the course, the ability of the physiotherapist to recognize cervical spine involvement, to understand how the neck is affecting the temporomandibular joint. So that was very nice to see. And also, that the dentist in the first day could actually contribute to the physiotherapist about understanding occlusion, understanding malocclusion, understanding the skills of diagnosing some observing into the mouth. Yeah. Intraoral therapy, palpation inside the mouth. So that was a really nice knowledge sharing between the two professions. [Jaz]Yeah, I would love more of that in the UK, and I think hopefully we can spark something with your visit. We’ll talk about that later. Let’s talk about a sign, right? There are symptoms and there’s signs. And one of the signs that the patient may be suffering in the masticatory department the stomatognathic system, the TMJ is a limited mouth opening. So just cover, for the dental student and going forward to dentist building up. What kind of mouth openings is a normal range of movement, including opening wide and left and right lateral. And then what point do we think something’s going on? And then as we talk about that, we can then try and discuss, okay, it is more muscular intracapsular and how you approach these issues. [Tzvika]Well, a functional range of motion is considered 30 millimeters and more, and a normal range of motion is considered 40 millimeters and more. In terms of protrusion, protrusive movement, we want around the 10 millimeters. And a lateral exertion, side to side, we want 5 to 10 millimeters. You can see that asymmetry is sometimes suggests a disorder, but not always. So, some healthy controls may present asymmetry in mouth opening, but if the asymmetry is associated with pain and with limited opening, that would be a significant issue usually. And- [Jaz]By asymmetry, Dr. Greenbaum do you mean like deviations and deflections? [Tzvika]Yeah, yeah. When you see someone, the opening pattern of a patient, when it’s not straight, most of us actually are not straight. So, it’s quite acceptable to see someone that is not opening completely straight. But if it is associated with limitation of movement and pain, then usually that will be clinically relevant. But if it’s just asymmetry and the patient open wide, more than 40 millimeters without pain, probably it’s just a sign and not a symptom. And many of us, more than 50% of us, are presented with signs. Luckily, only a minority of us presenting symptoms. [Jaz]But do you think there’s a merit in checking this in our patients so that we can be aware of the sign and see, can we perhaps give this patient some advice, recommendations to prevent this becoming into so bad that it then becomes symptomatic for the patient in the future? [Tzvika]Well, if you see a patient that can’t open more than 40, even if he has no pain, I would say specifically if it’s an older patient, I would say this patient needs to train the musculoskeletal system in order to prevent degenerative disorders. So it could be that if the patient is deteriorating from 40 to 38, 37, and in your checkups, when you take this measurement and you can see a trend of deterioration, for sure that this patient will benefit from physiotherapy. And also, you can instruct the patient to improve the range of motion quite easily. But you need to know how to do that. So that would be something very quick to learn in the course, but it would be something that you need to prescribe in an accurate manner. [Jaz]And the most common time where we struggle as dentists is restorations in the back of the mouth, doing root canals, crown preparations, fillings. And the dream patient is someone who can open 50 millimeters plus, okay? But there’s very few of these dream patients, right? Sometimes you get these men, and they can open just huge. And then you can have your hands, both your hands inside, your nurse can have two hands inside. And it’s just, that’s the best way to go. But unfortunately, many of our patients really struggle. Now I’m a big fan in general. I’m a huge, huge fan of placing a mouth prop or a wedge in the patient’s mouth. Because I said, what I say to patients, Dr. Greenbaum is, is the difference between you holding your elbow out like this. Okay. And letting that muscle tire versus leaning on something. Okay. And it’s the same if you’re stretching open, okay, you’re using all the depressor muscles and they’re having to work the whole time as your patient’s open. If you can give them a wedge, the way I sell it to a patient is, allow you to relax into it. I need to relax and that puts them in a relaxed frame of mind. The language you use is also very important. So that’s how I can help my patients to be more comfortable and get some mouth opening. But sometimes their mouth opening is so difficult to, you struggle. They struggle to even hold a wedge. So for a lot of our colleagues, we want our patients to be able to open a bigger. What advice would you give the dentist to help our patients to be able to open better, not only for their functional requirements, but to allow us to do our dentistry? [Tzvika]First of all, I would be a cautious with the patients that are sensitive. So one specific group within the TMD, which is a pain related group. These are patients that are more sensitive to pain and with these patients, you need to be very careful because if you facilitate or elicit a pain response in their treatment again and again and again, the chances for them to develop a chronic pain disorder is quite high. So, with this patient, I would not push them too much, but the other, the vast majority of patients. Like any exercise program, a gradual training for mouth opening with extra help of the hands like a stretch, self-stretch, I would just demonstrate it, with some extension of the neck, because the extensors of the neck provide a lot of force and web space can support between the lips and the chin. [Jaz]So just to describe to the audio listeners what Dr. Greenbaum was doing is he was opening big and then using the two hands as if he’s choking himself, but he’s choking just below the lower incisors basically. And then he’s giving the extra few millimeters of stretch while you are tilting your head backwards. [Tzvika]Yeah. and then you get some force, you get some strength and force from the neck to increase the leverage to open the mouth because you need to overcome a very tight muscle. The closest they can develop up to 90 kilograms in male and up to 70 kilograms in female. In order to overcome the tightness, you need to use a fair bit of strength. And just opening the mouth is not enough to get some overpressure, external overpressure from the hands and from the neck can help quite a bit. [Jaz]And how often would you advise your patients to do this before the appointment so that you can get some sort of extra four or five millimeters, which would be good for the patient in general in their function, but in terms of your treatment. So, what is the kind of regime that a patient would do? [Tzvika]If the patients are physically fit and they do stretch themselves and many patients do that today. I would recommend it as part of their routine. So, when they stretch the hamstring, stretch the low back, stretch the upper trapezius, et cetera, they need to remember to stretch the most closest as well, because this muscle group is very tight. It’s anti-gravity muscle because they always walk against the gravity, and they tend to get really tight. So as part of the routine for my patients that are also a sleep bruxist, so they clench the teeth during the night, that would be the first thing in the morning. So, before they brush their teeth, I recommend them to stretch it for 30 seconds twice, 30 seconds, and just to have a nice start of the day after a long tightening of the muscles during the night. [Jaz]Absolutely. What I find is my patients who are both sleep bruxist, but also awake bruxist, right? They spend so much of their time. with their masseters and temporalis, everything in a contracted state, right? Everything is shortened. Everything is contracted, right? And I can only imagine all the lactic acid building up. Is that still an accepted theory? The lactic acid, the buildup of lactic acid in the muscles? [Tzvika]Yeah, it’s a fatigue-ability of the muscles. So we are at the, there is a change in the physiology within the muscle. If you take any muscle and you work. Keep working it on a lower level, but for a long period of time. That would be the recipe to have pain. Because the muscle gets the oxygen level gets low, and the carbohydrate gets higher, and then the physiology of the muscle, that becomes a sick muscle. On the other hand, if you do it at night, that would be an excellent recipe to build up the muscle mass. That’s why the sleep bruxist, they would be hypertrophic, and the awake bruxist, they would be atrophic. Because when you do it during the day, and you do it for a long period of time, and it’s associated with pain, you start to lose the muscle mass. But when you do it at night, in a phasic way, so you do it in cycles. That would be, and you do it and then you relax, you do it, and then you relax, then you build the muscle. Of course, we don’t want it so much. [Jaz]It’s the dental gym, right? It’s the dental gym, yeah. And it’s these hypertrophic patients that crack teeth. Dr. Greenbaum, they crack teeth and they put our restorative materials and a lot of stress and strain. [Tzvika]It’s a gym for free every night, but not advisable. [Jaz]Absolutely. I mean, it’d be interesting to know, because you’ve obviously done so much training, PhD, about if you believe that changing the external factors can stop bruxism. So there’s one theory that once a bruxist, always a bruxist, and it’s very difficult to try and get someone to suddenly stop being a bruxist. They will still do some activity every night. Whereas, oh, if you just do this one therapy, or if we just reduce your stress, that you will stop bruxing. Anything that you’ve come across in terms of what you believe? [Tzvika]Well, let’s divide between the awake bruxism and sleep bruxism, because awake bruxism is a behavioral disorder with sleep bruxism is a sleep disorder, not necessarily they come together. A majority of patients are either sleep bruxist or awake bruxist. So for the awake bruxist as a behavioral disorder, we can approach it in behavioral therapy and we can change the behavior, can reduce it. Having said that it’s associated with mental stress. So you also need to address somehow the mental stress. Now you will not make these patients laid back patients. Yeah, the awake bruxist is usually their type a personality, but you can modify it a little bit. You can take the edge of it a little bit. The sleep bruxist is a different story. It’s a multifactorial phenomena. It requires some very accurate assessment for the sleeping hygiene. It requires a sleep laboratory requires some screening for medication use, alcohol use, and sometimes there is something to do about it, but many other times is mainly protecting the teeth. And the Botox is actually a nice intervention for some of these patients to reduce the strength of these muscles, but awake bruxism, behavioral change, sleep bruxism, sleep disorder, different approach, two different approaches. [Jaz]Do you believe there’s anything that we can, for those dentists who want to help the patient stop the sleep bruxism, stop the sleep disorder? What do you feel that they could be doing? So for example, because this is something, if they’re doing more sleep bruxism, their muscles are tighter. Their mouth opening is less. Like I give my patients occlusal appliances, but I color these occlusal appliances in. And I know that they’re grinding still, even though I’ve given them appliance, they’re still grinding on my appliance. I can see the proof. I can sometimes do lots of fancy dentistry, put all these crowns, get their joint within centric relation. But they will still Brux, because I know A, on their appliance, but B, things like a Brux checker, which I use my patients and I see that, no matter how beautiful everything is, how balanced everything is, how the center lines match up, they’re still Bruxing because they’re removing the ink from the Brux checker. So I’ve yet to come across the proof in my own patients that Intervention A will stop the sleep disorder. I’ve yet to find it, but that doesn’t mean it doesn’t exist. I’m open to the universe to learn. Is there anything that you’ve found from your research or from colleagues that has been suggested to limit, reduce, control sleep bruxism? [Tzvika]The literature speaks about sleep hygiene. So, getting into sleep slowly with no smartphones around, exercise, if you are exercising not very close to the sleep. Time to the bedtime, but to be honest, it’s a big challenge. I don’t see a breakthrough clinical intervention in that regard. Having said that we are researching today in our laboratory, the relationship between sleep bruxism and obstructive sleep apnea. Because they have some tendency to come together, and we are testing the option that one of them is actually feeding the other. We believe we are hypothesizing that the sleep bruxism might be perpetuating factor for obstructive sleep apnea by activating the mouth closers and inhibiting. The mouth openers, which are also stabilizing the base of the tongue. So what we want to see is if the patients with OSA, obstructive sleep apnea, that have also sleep bruxism, if there is some relationship between their severity of sleep bruxism and severity of OSA, and severity of mouth’s closest strength, and the severity of the obstructive sleep apnea. So that’s another thing that we are trying to assess, but how to get rid of sleep bruxism. That’s a big challenge. That’s usually it’s just by time, after the age of 60, it drops to 3%, before the age of 60, something around the eight or 10% of the population. So maybe it’s just by natural course. [Jaz]The problem with that data, Dr. Greenbaum, with the percentages are completely, based on literature and I see that the issue with the data collection on those is, are often surveys of patients while they’re awake. They’re like asking the patient, but most of the time patients are completely unaware of their habit, right? So my only issue with that data would be that I think that is underestimating the percentage of sleep bruxists out there. If you just look at, not you, but those who are listening, the work behind Giles Levine and looking at rhythmic masticatory muscle activity, 60% to 70% plus, there is a bit of movement of the masticatory muscles at night, which is rhythmic and that’s normal. And so if you just look at that, if you classify that as a type of bruxism, then already it’s so much. I guess the ones we’re concerned with as dentists and you guys, well, rehabilitating your patients in pain is those patients who are taking something that’s normal, which is rhythmic masticatory muscle activity, and really going above and beyond what should be happening, and now actually causing stress in the system, muscles being upset, and actually damaging the masticatory system. And so really to find out the true percentage of that, we need the studies, which we don’t have. And that’s why it’s a bit of a dilemma in terms of get that. Is there anything you want to add on that before I talk more about the regimes to help our patients? [Tzvika]We have today some clinical, we are trying to establish a diagnostic criteria for sleep bruxism, so it’s still not valid and reliable, but there is a consensus group with Professor Manfredini, Professor Winocur, and some other doctors in Europe and States that are trying to establish the clinical diagnostic criteria. I feel that we have the ability to at least suspect that our patient is, is asleep bruxist, because the hypertrophic is one. The muscular hypertrophic, specifically unilateral asymmetry. So usually, they have a unilaterally of the side, but they do it on both sides, but one side is more. And then the spouse is also questioning the spouse about the noises. That’s another important criteria. And then you can also observe the mouth. Of course, you guys, the dentists are excellent in seeing the erosion, but you can also see the marks of the teeth on the tongue and also the linear alba within the internal aspect. So I think when you combine these five factors, you can be quite suspicious that your patient is most likely to be a sleep bruxist. I think that the muscle hypertrophy is very important. From my perspective as a physio, when I see a patient with a very dominant masseter in temporalis and also medial pterygoid from inside, I can observe when I see the hypertrophy, I strongly suspect that I have a sleep bruxist in front of me. [Jaz]I absolutely agree with you. And I encourage all dentists to check, Dr. Greenbaum, a lot of dentists, they get out of the habit of doing a muscle exam and it’s just so, so quick and easy for us to do even externally and just even just to feel the size of the masseters, the size of the temporalis, takes very little time and I think adds to your findings, adds to your diagnosis, even influences exactly which type of restorations I will do, which teeth I will crown, what my crown will be made of to withstand those forces, who are the high occlusal risk patients, who are the low occlusal risk patients. So I think it’s absolutely fundamental. Now just to go back on track in terms of my patient can’t open their mouth anymore. You suggested that the exercise they do, is it just a once a day that we should recommend our patients do this or is it three times a day? Any sort of guidelines we can give and how soon along with other exercises, which you may go into, can we start seeing results from our patients so that we can have an easier time doing our dentistry? [Tzvika]First of all, for stretching, if you are not an athlete, if you’re not a specific athlete, so there is no limitation for stretching. You can say that the more is the better. If you are a contact athlete, like a football player, you don’t want to stretch yourself all day long because you need the muscle tonicity to protect you. But if you are just a human being that is not a professional athlete, and you want to improve the range of motion, you can do it as much as you want, not into pain. Yeah, don’t cause pain, but a strong believer in a daily activity. So functional activity that encourage full mouth opening. So patients that have been avoiding a full mouth opening, because they just got used that they can’t open. I would encourage them slowly to return to their, for example, if they were using to cut their, the apple into half. Then I try to avoid that. Stop avoiding that. Or stop the avoidance would be actually exposing the patients into stress. And this, I think, in my opinion as a physio, is the most important behavioral change is stop the avoidance and try to get used to think that you’ve been doing and stopped, been doing because of the limitation, but very gradually. So exercise first. And then activation in the daily activity cycle. [Jaz]Yeah, so the functioning is right and proper. And in dentistry, we call this guarding. Patients are guarding. When we get our patients to open, and just to check the mouth opening, they will open a bit. And then we say, can you open as much as you can? And then they open a lot more. Right? And so patients are sometimes guarding, and so it’s important to get them used to, they don’t actually exercise that additional range because they’re so used to, I completely agree with you. So definitely to encourage our patients to do it. And as in the physio world, as you guys say, motion is lotion, right? So it’s good, it’s good to use it. Now, how might this change? And so firstly, let’s talk about pain, sorry. If the patient is experiencing some discomfort. Is there any guideline? Like, sometimes I say, well, if you haven’t been stretching something for a long time, A, go gradual, but you might feel a stretch, right? A stretch is a sensation. When you stretch something, you feel a stretching sensation. It’s not the most pleasant thing in the world. It’s not the worst thing in the world either. So I think it’s important to expect a little bit, but I say, if it gets more of a six out of 10, then stop doing it. Basically, don’t go beyond that limit. Find that safe limit for you. Any guidelines on that? [Tzvika]Yes, I totally agree with you, I think that we need to reassure the patients to tell them up to that point is okay, so 5 out of 10 I would say, up to that is fine, more than that is not fine, and specifically what you feel after the stretch. If you feel after the stretch that you’re still in pain, it means you did too much, but if one or two minutes after the stretch you feel normal or even better than before, that’s a very good sign. So I tell him not only during the stretch, but how do you feel a quarter of an hour after the stretch? Do you feel well after that? You should feel better. You should feel. If you feel more pain after the stretch, maybe half an hour, or if you can’t activate your musculatory system after the stretch, that means you did too much. That means maybe there is a disorder that requires a rehabilitation. That means maybe there is an obstacle, a mechanical obstacle that a well-trained physio need to diagnose and help you to overcome. [Jaz]Well, let’s talk about that. So, what if a patient has got not so much muscular, but they’re having intracapsular issues and they’re getting locking and perhaps we need to focus more on that. So, if someone’s trying to stretch open and they’re getting a pain in the preauricular area and the TMJ area, how might your rehabilitation change for that patient? Or certainly from a dentist perspective, we know that, okay, just because we get their muscles happier, they’re still the disc displacement to deal with. So what advice would you give to the dentist to help our patients whose diagnosis may be not purely muscular? [Tzvika]Well, the discogenic patients are more complicated because the potential to irritate them is very high. And the inflammatory potential is higher. With the muscular patient the inflammatory potential, the irritability is not very high. But with these patients, we need to be very careful, specifically if they have intermittent locking. The patients with intermittent locking, they are unstable, and these patients need to be diagnosed well and need to be rehabilitated in a very accurate way, more in proprioceptive exercise. So more training the muscular compensatory factors. But those who have this displacement without reduction, so that they are permanently locked, usually are more mechanical patients. And we can actually invest more energy in stretching depth. So we can actually go a little bit further with it. Intermittent locking, be careful with them because they are likely to have inflammatory response and the more this displacement without reduction of permanent lock and you can dare a little bit more to instruct them to stretch. Having said that, this patient need to be rehabilitated by physios. I think that a dentist by himself should not be the only clinician to deal with this patient. So it’s exactly the synergy that we need with a rehabilitation practitioner and with a dentist that has a case manager and diagnosis. [Jaz]100% agree and I think a good guideline for dentists listening and watching to this it would be that if you have a patient who’s just got tight muscles and you’re just concerned that give them those stretching exercises. And if it’s just a sign, not a symptom, then monitor them, but then maybe plant the seed in their head that, look, you might benefit, have you seen a physio before, this TMJ physios could really help you. And so let’s keep that, that we may be able to consider it. If someone’s got displacement with intermittent locking or as a displacement without reduction. So they’re permanently locked. As you said, these patients, you really, really, really should try and find your local TMJ physio and work with them to rehabilitate this patient. You’ll really improve the quality of life, the patient, you’ll improve your dentistry because you get your patient to open bigger. Which leads me to my final question. What are the kind of results we can expect? How much more mouth opening? Because I’ve read some papers. I’m very impressed, but guidelines. Now, how much more either as a percentage or as millimeters improved opening can we get from our patients who have physio assisted rehabilitation? [Tzvika]Well, if it’s a pain related patient, if we can professionally reduce their pain and their fear and the fear avoidance. We can improve them, for example, from 30 millimeters without pain until 50 millimeters without pain. So, 20 millimeters would be a very expectable result within few sessions. But if it’s a patient with an intrarticular disorder, displacement without reduction, with limited opening, that would be very gradual. So if you improve them from 25 to 29 within one month, that’s a good success. That’s quite a good process of progress. With the patients with the degenerative joint disease, usually if they were untreated for a long period of time, it would take a bit more time to get improvement. If they just started to deteriorate, then we can quite quickly improve them. So it depends how long they’ve been waiting before seeking for help. [Jaz]I think a good guideline for dentists is to start looking at your patient’s mouth opening. You can use a three-finger test, for example, as a very basic crude screening, but to get a ruler, it’s just so quick and easy as part of your new patient examination to do that, right? [Tzvika]Yeah, for sure. A ruler, we have no excuse to avoid the ruler. It’s so cheap. It’s so accurate. It’s valid. It’s reliable. The therapists that are taking my courses, they get it as a small present, small Israeli present from China because it’s all usually made by China. But I tell them you have to use it because it’s really simple and it gives you a very nice thumb rule if your patient is getting better or worse. And the patient love it when they are measured. They love it because they see that you are monitoring them. They see that you care about their changes, and I strongly recommend to use it. [Jaz]It’s a bit like when we are doing a mouth cancer examination, which we’re doing a mouth cancer screening, right? If we tell our patients, hey, I’m going to do a mouth cancer screening, and then they go away thinking, wow, this dentist did a mouth cancer screening. I feel so good. I feel like I’m good that I was checked and that’s good. Whereas some dentists will do it, but they’re not telling the patient that they’re doing it. So the patient never knows what’s happening. So A, it’s good to tell your patient what you’re doing. And B, this is just like that. If you tell, if every patient you see, new patient, Okay. And then recall as well. You just measure and say, hey, I’m going to measure your mouth opening. I’m going to see where you score in terms of normal. And then it’ll be really good for me to check you over time. So I can pick up on any functional disturbances and look after you. Cause it’s something I’m very passionate about is the look, the muscles of the head and neck as well. And they’d be like, wow, this dentist is very detailed, very thorough. No other dentist has done this for me before. They will get an idea that, yeah, this is a really good thing. So I would heavily encourage dentists to do that. The stretches that you recommended are great and also to pick up those patients who are perhaps a bit more involved in terms of intracapsular issues or degenerative and to really involve your physio. That is the best thing you could do for your patient. Now I know that when you come in December, you’re going to cover a lot of this stuff the way I think you’re doing it I’m not organizing it, but I am partaking I’m supporting because I want dentists to learn more about TMD. I want physios and dentists to have more synergy in the UK because you’re visiting the UK. So I’m assisting and organizing this course and I would like everyone, all the dentists listening to learn more from you. It’s a very reasonable offering as well. The way I suggested it is that you do live webinars on Zoom first. Because we want to have the theory in front on a laptop and catch up with the recording. But when we come to the day, the much, as much hands on as we can do, and as much hands on that we can observe, that’s the best thing. So what kind of things are you looking to cover in this very bespoke special course that you’re organizing for dentists? [Tzvika]So we’re going to follow the acceptable diagnostic criteria for Temporomandibular disorder, the DCTMD. It’s an excellent manual. It’s like a recipe that you follow, and you can get to the specific diagnosis in a UK, Canada, Israel and Belgium with the same patient. And it’s an excellent tool. So we’re going to cover that to learn how to use it and how to follow it and how to use the decision trees to get to the specific diagnosis. So that would be a very important part. And then, according to the diagnosis, based on the diagnosis, we are going to understand the strategy to rehabilitate each one of the specific diagnosis, patients with a specific diagnosis, pain related, what’s more likely to be the strategy for management. The intraticular and the degenerative. We will also learn how to understand if the neck is likely to play a role in the clinical presentation or not. That was my PhD. So I’m going to describe it and to present it and to show you in a practical way. A very quick screening to make a decision is the neck likely to play a role or is the neck not likely to play a role in the clinical presentation. If it is, then of course for the physiotherapy very quickly, if not, you can keep managing the patient. Without considering too much the cervical spine. So that will be another component that we will discuss and train and practice. [Jaz]From teaching TMD courses. The dentist, myself, I found that a lot of time just to get the basic palpation skills is very important for dentists. Dentists often when they’re feeling like when they’re supposed to be palpating over the joints and the condyle, they’re actually more in the origin of masseter. And I also find that dentists are usually not palpating firmly enough. They’re a bit too gentle. So, are you going to be covering the more basic, as per the diagnostic criteria, exactly how to do the palpations for the dentists? [Tzvika]Yeah, part of the DCTMD is a calibration, is a calibrating the assessors. And it’s about how to build the stress on the palpation and how to consistently find the specific zones and area to cover the whole temporalis, the whole masseter, and specifically the TMJ. So definitely we’re going to specify the palpation skills of the dentist in order to accurately diagnose patients. [Jaz]Amazing. Well, we look forward to welcoming you. I will make it the show notes have the link that can click on. The website can easily make is protrusive.co.uk/greenbaum as G-R-E-E-N-B-A-U-M. So, it’s B-A-U-M, Greenbaum. And then that will take you to the landing page once you’ve had fully finalized it. And like I said, I have no financial interest in this, except I just want education to be widespread. And I’m excited to come and learn from you. I’m excited for those who’ve learned with me, splints and stuff before to come and learn from a world expert physio. There’s so much we can learn and share with each other. And I know you’re coming to do teach physios as well. But I think it’s a very special thing to organize for dentists. So I’m excited to learn from you further and also to allow accessibility for dentists in this event to get exposure and access to you as well. [Tzvika]Definitely. Yes. I think this cooperation is highly important from the few first courses I’ve given in the UK. I feel that the gap is really high. There’s a big gap to close in the favor of patients that having temporomandibular disorders. And that means the cooperation between diagnostic clinicians and rehabilitating clinicians is required and that would be an excellent start for us to be in this cooperation between the two professions. And I want to thank you personally for inviting me for this podcast. It’s been a real pleasure and great opportunity to share my knowledge with you. [Jaz]Yeah, thank you so much. And yeah, I look forward to seeing you on the 1st of December and hopefully much more from then as well as it’s great to finally meet you in this way. I know we had a zoom as well, but yeah, it’s great for you to share your knowledge. Thank you. [Tzvika]Looking forward to learn from you as well. Jaz’s Outro:Well, there we have it guys. Thank you so much for listening all the way to the end. Now, if you want to claim some CPD for this educational episode on the web app, for example, on your laptop, head over to protrusive.app or on your phone. If you already got the app downloaded, answer a few questions and my team will send you out a certificate. If you’re a dentist who’s new into TMD and you’d like to learn about diagnosing TMDs and how we can work with other healthcare professionals to start helping our patients with temporomandibular disorders, and if you’re in the UK or even if you’re in Europe, come along to our event in December. It’s not my event, it’s Dr. Greenbaum’s event, but I’ll be there to support him. It’s an area of dentistry that’s not as sexy as veneers and bonding, but it’s so, so important. It helps our patients to be pain free. So, if you’re interested in that, head to protrusive.co.uk/greenbaum, that’s G-R-E-E-N-B-A-U-M, that’s his surname, and I’ll make sure that redirects you to his event. I hope to see some of you there. Otherwise, to all the podcast listeners, all the watchers, thanks so much for staying all the way to the end once again. I’ll catch you same time, same place next week.

Dr. Neel Jaiswal, founder of Professional Dental Indemnity, discusses the difference between dental indemnity and insurance. He provides transparent advice on choosing the right policy for your career stage. The podcast explores the benefits of insurance, the shift from mutuals to insurance, and the importance of uninterrupted coverage. The speakers also emphasize the need for clear communication and understanding when choosing a provider.

Ovate pontics are what you choose when you want the best aesthetics for fixed dental bridges – but how do you go about prescribing this to your lab? https://youtu.be/ffg0gX4L8ng Watch PDP158 on Youtube How do you carry out ‘pontic site development’ and how can you assess the soft tissues for suitability? Get your onions ready, Protruserati, it’s another cracker with that man Dr Jason Smithson who will make ovate pontics tangible. We’ve also made a kick-ass infographic for you to download alongside 2 PDFs recommended by Dr Jason Smithson, summarising all that Dr Smithson taught on this episode. [Also available in the Protrusive Vault for premium subscribers] Protrusive Dental Pearl: Jaz’s Rule for Resin Bonded Bridges For Metal winged adhesive bridges, do not accept more than 1 compromise For Zirconia RBBs, do not accept any compromises! Examples of compromises: small abutment teeth (and thus smaller surface area for bonding), poor quality enamel, awkward path of insertion, dodgy occlusions etc Join us on Saturday 30th September for Occlusion and Communication Day at London Heathrow – amazing speakers on 2 huge topics! As promised, check out the PDF on Ovate Pontics by Professor Bill Robbins and more about the E-Pontic here. Learn more from Dr Jason Smithson and his Restorative Programme. Also, check out his courses with Spear Education. Highlights from this episode to follow. Robbins Ovate Pontics PDFDownload If you enjoyed this episode, you will also like PDP132 Success with Resin Bonded Bridges Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month? Click below for full episode transcript: Jaz's Introduction: This episode will be the definitive guide to all things OVATE PONTICS. Now, we actually cover bridge pontics in general, and when we qualified from dental school, we only really learned the modified ridgelap or the ridgelap. Jaz’s Introduction:Look, they’re okay pontics, they do the job, but they’re ugly. Ovate pontics are egg shaped or bullet shaped, and they emerge from the soft tissues, and they look really natural. As well as that, they offer really good cleansability as well. So Ovate Pontic is the best kind of pontic you can aim for. But it’s so difficult to find good content online when it comes to Ovate Pontics, until now. I got on, once again, Dr. Jason Smithson, who, to me, is the best dentist in the world. He is amazing. I’ve been to so many courses. He’s taught me so much. And it’s just always a pleasure to have him on the podcast. I tried to really extract as much as I could from Jason Smithson during this episode to try and cover a lot of depth, but also a bit more breadth around this topic. What I also did in the editing stages of this episode is I really stacked it with lots of visuals, because sometimes when you talk about topics like this, when it’s not visual, it’s very difficult to follow along. Now, for all my Protruserati audio listeners, don’t worry, all of it can be followed along by audio, but when a visual is really going to enhance the learning, I’ve put that on the screen. So for those of you who are watching on YouTube or on the app with the premium notes, you’re probably going to gain a bit more. So I encourage you if you can make the time to do this, like an on demand webinar kind of thing, right? Just study all the visuals that will really compliment what we’re talking about. In this episode, we discussed case selection for ovate pontics and all the nuances, like how deep do you actually go into soft tissues, which kind of soft tissues are suitable. What if you don’t have enough soft tissue and everything you have to do to actually develop your pontic site. At the end of the episode we also see the return of Am I Naughty If, because I shared with Jason a shortcut way of working with ovate pontics to try and bypass the healing time and I asked him what he thought and the answer is very interesting. So we do Am I Naughty If. [Jason]I don’t think it’s a terrible solution and actually it is possibly a very acceptable solution for posterior units. [Jaz] Protrusive Dental PearlI share with Jason how I cheat, and so let’s see what he has to say about that at the end. Before we join the main episode, I will give you my Protrusive Dental Pearl. If you’re new to the podcast, welcome to Protrusive Dental Podcast. It’s great to have you. If you’re a veteran listener, you know that every PDP episode, I will give you a Protrusive Pearl. So this pearl, this piece of advice I’m going to give you is my rule when it comes to adhesive bridges or resin bonded bridges. I got to a stage where lots of my colleagues are messaging me with advice for Resin Bonded Bridges. Is this tooth suitable to be an abutment for a Resin Bonded Bridge? Can I restore this case with an RBB? So I’ve got lots of these cases, and of course, all these colleagues and friends ask me for advice. I want them to succeed. I want their Resin Bonded Bridges to last a long time, and they certainly can. Like my predecessor, where I’m working now, he retired, and I’m seeing bridges that he placed 30 years ago. And we know from the literature that Resin Bonded Bridges, when designed well, in the right occlusion, they really can work. But sometimes we get stuck and we need to know, is this case suitable for a resin bonded bridge or is that too ambitious? So I’ll share with you my rule. When it comes to metal Resin bonded bridges, what I mean by that is the wing, aka the retainer, is made out of metal. And obviously the pontic is usually out of porcelain or acrylic. For the metal RBBs, I advise never accept more than one compromise. So you’re allowed one compromise. So what I mean by that, what’s the compromise? Okay. This could be an aesthetic compromise. This could be the abutment size. Maybe the abutment is not ideal. It’s a bit too small. Maybe it’s the occlusion. It’s a bit risky occlusion. It’s a bit edge to edge. There’s not enough. Overjet perhaps, or maybe the path of insertion on the bridge is not ideal. So you’re looking at one sort of compromise, and sometimes we can accept this. When there’s more than one compromise, i. e. you have a small abutment tooth, that really is not going to give you the right surface area to bond, and you also have an occlusion that’s not ideal, then I would suggest that’s not a case for resin bonded bridges, unless you change something about those two factors. When it comes to Zirconia based Resin Bonded Bridges, I say no compromises, okay? Really, I want everything set up and I want no compromises here. Because the long-term data, whilst it’s really good, I would encourage you all to check out the papers by Matthias Kern, showing the 10 year recall and success rate of Zirconia Resin Bonded Bridges, especially to replace lateral incisors, like 92%. That’s really impressive. But I just think the track record with metal RBBs in the papers just spans so many more decades. And also it’s a more predictable bond. So Zirconia Resin Bonded Bridges, no compromises. Make sure the occlusion is perfect. Make sure everything is perfect and they’ll do really well. The data is there to prove it. But for metal ones, maybe you can accept one compromise. So that’s my rule for Resin Bonded Bridges as today’s pearl. Let’s now join the episode with Jason Smithson, and I’ll catch you in the outro. Jason Smithson. Welcome back to the Protrusive Dental podcast there. How are you? [Jason]I’m good. Got a couple of months off. Well, off. That means not traveling. So, yeah, I’ve been at home for a couple of months and I’m just in the practice two or three days a week and although I am to spear in Arizona next week, but I consider that off. I go to Arizona four times a year and then I go to the U. S. usually another twice, I was in the US in February for Academy of Restorative Dentistry, which you may know in Chicago. And then the other long hauls are Australia, which are once or twice a year, and then a bit of Far East. So yeah, not getting on the train at 10.30 at night is a bit of I consider that to be a holiday. So that’s good. [Jaz]We’re all very accustomed to your photograph at this train station with the shoes on. Yeah, I lost access to my, your shoes are famous. I lost access to my own Facebook account, but funnily enough, can you believe it, right? So, you’re no longer my friend on Facebook, so I’ll have to add you on my new account. But yeah, I miss seeing your shoes at the train station. That’s like a hallmark thing, so we admire that. So, thanks again for joining us. No shoes required for this one today. We’ll be discussing, we’re both doing this. That’s what we’re talking about. Ovate pontics it’s a deep dive and a very small area, but there are a lot of questions, especially if you imagine Jason. Young dentists qualifying with very basic skills in fixed prosthodontics all together. And really, as they progress, maybe five, six years later, they come across cases. Okay, you know what? I’ve seen some cases whereby I could do an ovate pontic. And then we start looking online as you do for tips and advice, and there’s not much out there. So, I’m hoping that this will become a definitive guide to Ovate Pontics, that you can share your years of experience. Like when I went to your course on VertiPrep, so BOPT technique and vertical preparations, you talked about the E Pontic, which I think might be a part of today, but I know there’s so many amazing cases and I’ve seen your soft tissue cases and stuff. So, everything is brilliant and everyone is really excited to learn from that. So I guess where to start would be just for the, maybe the dental students, the younger dentist. There are different types of pontics that are generally used for bridges, and what are the main ones that we use currently? [Jason]Alright, so I’d start off by defining pontic. A pontic is a prosthetic false tooth, right? So that’s for the dental students. And that could be related to a bridge, which is the obvious. Or it could be related to an implant retained bridge. And actually, I first started doing ovate pontics by default, and I didn’t even realize I was doing it when I did immediate dentures. So there’s also an ability to form an ovate pontic site when you do an immediate denture. So there’s kind of three applications. Now, historically, there are four main types of pontic design. Historically, we had what was called a hygienic or sanitary pontic. I mean, I’ll be honest with you, I’ve never done one, but it’s basically a rod that joins. Two retainer teeth together, so you’ve got a crown prep on, for example, a lower first premolar and you’ve got a crown prep on a lower first molar and you’re replacing the second premolar and they’re just joined with a little stick of material and that classic- [Jaz]Like an occlusal table, right? Is this a big table? [Jason]Yeah, yeah. It was originally done in gold. So you got literally what looks like a bridge, not a dental bridge, but an actual bridge. And the idea was that you had a big blow through hole so that the patient could clean it effectively, hence the name Hygienic or Sanitary Pontic. Now, that works very well for chewing on, but it looks hideous. And secondly, they discovered it actually wasn’t sanitary at all because people got food stuck in between it. You can imagine chewing a sandwich and getting tons of bread stuck in between it. It’s just disgusting. So although it was easy to clean. When you’re chewing, you basically get the best part of a takeaway meal stuck between your teeth. So, it’s not ideal. So that is really, you might see them in your practice, but it’s really, it’s in the history books now. So that was the first up, that came out in the 50s really. And then we had a pontic, which is called the ridge lap. And what that means is your dummy tooth, your pontic tooth, laps over the buccal and the palatal of the ridge, hence ridge lap, because it laps over the ridge. And actually, that can be made to look reasonably aesthetic, but because the intaglio surface, in other words, the fit surface of the pontic is concave, it goes over the buccal and over the palatal. It’s really tricky to clean, so people couldn’t get superfloss underneath it, and what you end up with when you have a ridgelap pontic is that you get inflamed tissue and it’s red or purple and you get bleeding and it’s not that great to look at. [Jaz]Is that the same, Jason, as a saddle pontic? [Jason]Yes, yes, it would be. That would be another name for it. Now, that should be consigned to the history books. Sadly, I’m actually seeing quite a lot of that recently. It went out of vogue, and now it’s come back in. When I look at cases on Instagram where, particularly, where people are replacing significant hard tissue defects with implants, and they can’t build bone, and they can’t build soft tissue. They’re oftentimes replacing that with acrylic, and what they’re getting is a ridge like pontic, and it looks great. I won’t name names, but I saw one on Monday from somebody who’s very, very well known. It looks great on Instagram, and you get all the oohs and ahhs and 50, 000 likes. But from a bio point of view, from a tissue point of view, it’s a really, really bad idea. You might get a happy patient then, but when you go back to it, when you dismantle it long term, it’s going to look horrible. I dismantled one last week and it just was hideous inside, it stinks. So we got the sanitary and we got the ridgelap or the saddle. So the next one on was a modification of the ridgelap. What they did is they took the palatal bed off. So what you’ve got is something that sits on the existing tissue on the facial or the buccal side, or American language dropped in there. Sorry about that, on the buccal side. But the palatal bit’s been removed. So you’ve got something which sits on the tissue facially, but is more cleansable. And that’s what I was trained with. So I spent the first and I think it’s fair to say, most people in the UK, and frankly, probably most people worldwide, are trained with that still. And it offers some advantages. The first and obvious advantage is it’s, it doesn’t require any intervention from the dentist. You just do your crown preps, or your implant placement. And then you take your impression and the technician does all the work and you seat it and it’s done. So it saves time and therefore saves cost for the patient, usually. And the downside is that they don’t look all that great, generally. You can generally see the margin, because the margin is super gingival, you can see the margin where it touches the tissue. And it can be satisfactory for some patients, but for others not so much. So then, when was that invented? 1980 actually, by a guy called Abrams, came up with the ovate pontic. So the ovate pontic is essentially a pontic where the bit that touches the tissue is ovate. In other words, bullet shaped. So if you can imagine the tip of the pontic where it touches a tissue is a bullet shape and we could talk about the biology of it a little bit later on, maybe, but because it’s bullet shape, in other words, it’s entirely convex, it’s very flossable. And also it’s supposed to go into the tissue. We can debate this, but on the whole, probably about one to two millimeters, let’s say one to one and a half millimeters into a dimple that you’ve created in the tissue. So that actually your margin, in other words, where the pontic meets the soft tissue, is actually sub gingival. So it would appear like it’s coming out of the tissue and the advantage of that is that you get massively better aesthetics. And then you do get oohs and ahhs on instagram and also because it’s ovate it’s cleansable. The downsides are you’ve got to condition the site in other words you’ve got to make the tissue that you’re sitting the pontic on have a kind of dimple in it. (Name unclear) has a lovely expression. He calls it eggs in a nest. It’s kind of like an egg in a nest. It’s got to sit in a nest. So you’ve got to create that. And that can either be created post extraction, in other words, the tooth’s out and you’ve got a ridge to deal with, and there are ways of dealing with that post extraction. Or it can be dealt with pre and during extraction. In other words, you’ve got a tooth which is compromised, so it’s got to come out, and you extract the tooth, and then you conserve the extra or some degree of the extraction socket. With your temporary, the temporary could either be a temporary acrylic fixed bridge, it could be conventional, or it could be a temporary acrylic adhesive bridge, or it could be a denture, and there are pros and cons for each of those. So basically we’ve got four different, to a long, long way around your question, but we’ve got four different options for pontic designs. The ridgelap and the hygienic have gone, and nowadays we’ve just basically got the choice of a modified ridgelap or an ovate, and there’s a slight modification to the ovate, which is what you alluded to earlier, which is the epontic. So there we go. So that’s it. [Jaz]Excellent. Well, thanks for that. A really nice summary. I think that’s foundational. And I think now we’re on the same page for those listening and watching. I just like to know in your practice now, what percentage cause you do such a lovely aesthetic work, what percentage of the pontics that you do are going to be modified ridge lap and what percentage will be a ovate? And then does that change anterior to posterior? I mean, just because you can do an ovate, is there ever a good reason to do an ovate posteriorly, perhaps to a cleansability? You let me know. [Jason]Yeah. So, the main question is ovate versus modified ridgelap essentially, isn’t it? [Jaz]Mmm-mm. [Jason]I would say in my practice, I virtually always do ovate or E pontic, right? I very, very rarely do modified ridgelap. However, I would couch that by saying that I work in, I’m not a specialist, but I work in a specialist practice, and the vast majority of my patients are either referred to me or come to me direct because they want a specific prosthetic or aesthetic outcome, so my patient population is skewed. The only time, so I think there are very few reasons why I wouldn’t want to do, an ovate pontic. The only reasons why I wouldn’t want to do an ovate pontic, and I’d do a modified ridge lap, are the patient isn’t prepared to come back and have the side conditioning, and that, and oftentimes, dentists say, ‘Oh, well, the patient will pay for it.’ Oftentimes, it’s usually time. In my practice, you’ve got a patient who’s not that aesthetically bothered, and they’re just like, I just want to get on with it. I want to get this done in two visits. Not five. That would be one reason. Another reason, maybe there’s some medical reason that would preclude it. For example, I can’t think of a really good one, but perhaps uncontrolled bleeding issues or something like that. Or well actually maybe a patient on bisphosphonates that was- [Jaz]I was thinking IV bisphosphate maybe, yeah. [Jason]That would be a good reason. I’ve not encountered it in my own practice, but certainly when you modify the site post extraction, you may end up touching bones. So at that might not be a good idea for a patient on bisphosphonates. So just something that, something I should put in my lecture. ’cause it’s just something that occurred to me, but they would be the only reasons really. [Jaz]And posteriorly as well, by default if you’re doing a posterior bridge you do an ovate pontic as well, yeah? [Jason]Yeah, because like, in the posterior, in my practice, vast majority of the time I’m either doing implants, or Adrian, my implantologist, places the implants, I restore them, but I’m restoring an implant, so I’m going to put provisional on there anyway. So if I’m going to put provisional on there anyway and load the implants, then why would I not use that same provisional to form an ovate pontic, given the actual time to, the extra time to do that is probably less than five minutes. Or if I’m working on teeth, the vast majority of time in my practice that I’m working on posterior teeth with bridge work, I’m tending to do a vertical margin. And there are a couple of different reasons for that. The first and most common reason is I deal with a lot of older patients who’ve got significantly compromised teeth, and we do vertical margin to deal with those compromised teeth. And the other reason may be that I’ve got younger patients and I want to be more conservative, so I do a supragingival vertical margin to be more conservative. It’s actually quite unusual for me to do a conventional chamfer margin for a posterior bridge. And again if you’re doing vertical margin, you need the provisional to condition the tissue for, I know this is debatable, but 40 days. So why would I not do an ovate pontic at the same time? So that’s where I appreciate I’m in a slightly skewed practice, but that’s kind of where I am with that. [Jaz]And for those of you listening, you weren’t watching as Jason was saying that I was smiling because when Jason says something that is very, and I’m already doing that in practice, it makes you feel really good. So that’s fantastic because I’m a big fan of vertical for, as I learned from you as well. So that’s great that we have that and you passed that on to me. So I feel good about myself. Now there might be some ways of me doing ovate, which you might probably disagree with, and I’m totally cool for you to tell me I’m an idiot, Jason. Okay, we’re going to come on to that later. And at the end, yeah, I know you would. At the end, we’re going to talk about the E pontic, which will be called. Just in the middle bit, there could be another reason, perhaps that you maybe would be a bit more challenging to do an ovate pontic. So particularly that scenario where I’ve considered doing an ovate pontic before, but then I do the bone sounding, which we’ll talk about suitability of that site to receive the bullet shape ovate pontic, there was like, one to two millimeters, it’s just very thin tissue. And then to actually get an ovate pontic, I’d have to do bone removal or something. So we’ll talk about that. So let’s talk about maybe what is bone sounding and how much is the ideal amount of tissue that you should have to be able to consider an ovate pontic? [Jason]Alright. Would you mind if I just rewound and just took a look to the considerations for pre extraction and post extraction because that would lead on to quite sensibly? [Jaz]Alright. [Jason]So, let’s look at post extraction first. So, you’ve got a patient comes in with a missing tooth. They’ve had the tooth out, I don’t know, several months, maybe even years ago. They’re missing a tooth, the ridge is relatively flat, and you’ve made a decision that you’re going to prep the adjacent teeth and place a bridge. So if you want to form an ovate pontic, you’ve got to condition the saddle, the site. So what you need from a biological point of view is, you’ve got the bone, and then covering the bone, you’ve got connective tissue, and then covering the connective tissue, you’ve got epithelium, right? Now, as I alluded to earlier on in the presentation or the podcast, the ovate pontic has got to go into the tissue by about a millimeter to be stable, at least. I wouldn’t make it more than two millimeters, but it’s certainly got to go in, because that makes it difficult to clean. But it’s got to go in at least a millimeter to look decent. So you need a millimeter. You also need a millimeter thickness for the epithelium. You also need a millimeter thickness, at least, for the connective tissue. And that was described by Gargiulo under biologic width. So, when you bone sound, and we’ll come to that, you need to have at least three millimeters from depth of tissue to allow you your millimeter for your pontic, your millimeter for your epithelium, and your millimeter for your connective tissue. There is another bit of research, I can’t remember the name of it, I think it’s a guy called (unknown) off the top of my head, if I misquoted in my apologies. And he talks about prosthetic biologic width. So there’s biologic width of connective tissue and epithelium, but their study showed something like two and a half to three, so a little bit thicker. But anyway, what you would do at that point is you would look at the patient, and you would nut them up, because people don’t like to have this done without being anesthetized. And you would take a periodontal probe, a non-ball-ended periodontal probe, just a regular periodontal probe, and just advance it onto the saddle, onto the tissue, and press down, and it will penetrate initially the epithelium. And then the connective tissue. And then you’ll hit bone. You will feel some resistance as you hit the connective tissue. It’s not bone at that point. You need to feel the positive “bung”. And then you look at the measurement. Now, if you’ve got 3mm, you’re kind of good to go and it’s going to be all in soft tissue. If you haven’t got 3mm, if you’ve got 2mm or less, what that means is you can still create an ovate pontic sign, but you’re going to need to remove bone. All right, because you’ve got to have the room to get the pontic in, the soft connective tissue and the epithelium. Now that creates a few problems in so much as you’ve got to be really careful where your gingival margin is. So the way to do that is what you would do is you would do your crown preparations. Once you’ve done your crown preparations, you would fabricate your temporary. And what I would then do is get your pontic the right shape as you shape your temporary and adjust the occlusion and get everything right from an aesthetic point of view. So your pontic is the correct shape at the gingival margin and the correct lengths. Then, the next thing I do is I take a really, really thin Sharpie marker, Indelible marker pen, and just draw around the gingival margin with the tabs in place before you cement them. [Jaz]At this stage, Jason, at this stage, what you’re dealing with essentially is a modified ridgelap, right? That you’re going to convert to an ovate? [Jason]Absolutely exactly, yeah. So, you’ve then got a little U shaped marked on the tissue, which is exactly where you want your ovate pontic to be. [Jaz]The gingival zenith we’re talking about, right? [Jason]Yeah, that’s a subtlety, and it takes a little bit longer to do it like that, but it means you put the site in the correct position, because often times people just blindly burr, and then they end up with a gingival margin which is lower than it should be, and it just looks terrible. So you mark it with a marker pen, then you take your temporaries off, and some people use a football bur, coarse diamond you want, and some people, including myself, use a round diamond. And what you need to do then is to actually use the burr to sink, to make a divot in the soft tissue. Now, going back to the bone sounding, if you know for sure that you’ve got 3mm or more of tissue depth, you can just burr a millimeter, maybe a millimeter and a half into that soft tissue. And you would now know that that’s going to heal up. Okay? And you’re going to have a millimeter of connective tissue and a millimeter of epithelium, so you’re good to go. So that’s the simplest one. Oftentimes you haven’t, and if you haven’t, you’re going to need to burr more because you’re going to need to burr into bone, right? So what you’re going to need to do is to take that burr, into the soft tissue, and burr through the epithelium, through the connective tissue, until you hit bone. And the next question is, how much bone do I need to remove? And the answer would be, until your burr is sunk three millimeters into the tissue, from the gingival margin. Right? We’ll bleed quite a lot, and once you’ve done that, you know you’ve got your millimeter for your pontic, your millimeter for your connective tissue, and your millimeter for the epithelium. Sorry to keep repeating that, but I need to go in. We’ll bleed a lot. That’s not a big deal. All you need to do then is, I just use something, some people use electrosurgery, but I think that tends to be a bit painful, and it stinks. I just use astringent or ViscoStat. Clean it up with ViscoStat, it will stop bleeding. [Jaz]It might go black though, so let’s reassure everyone that it’s going to go horrible. [Jason]It might go black, but that’ll come back. Yeah. Then, what you do is, some people use flowable composite, I use regular composite. You just put a little bit of regular composite on the apical part of your pontic, and sit it into the site that you’ve just created. Then you light cure it. It will light, it shouldn’t technically, but it will light cure through the tissue. Oh, a little aside, before you put the composite on the temporary bridge, I always put a little bit of Signum from Corsa. It’s a modelling resin, it’s designed to link acrylic to composite. So anyway, you sink this composite into the site you prepared. I light-cure it. Then you take it out and it will be rough as rats. So then you shape it until it’s convex all the way around. So it’s a dome shape. Now, you’ve then got to make sure it only penetrates a millimeter to a millimeter and a half into the socket. Because if it’s right on the bone crest, it’s not going to heal very well. So what you do is you replace your bridge after you’ve trimmed it into a dome shape. And then I just take a pencil, a propelling pencil is really good because it stays sharp. And then you mark around your gingival margin onto the bridge with the propelling pencil. Take it out and you’ll have a pencil line. And then you measure, I would just do, say a millimeter and a half. Measure a millimeter and a half from the pencil line apically. And then trim the pontic to that level. Then you can reseat it on what you’ll have in the site you’ve prepared as a blood clot at the base. Some space. And your pontic. And then you leave it alone. Now, how long do you need to leave it alone? Well, when you cement it obviously. And then leave it alone. Be very careful with your cement cleanup. A little tip I do, is I place the temporary bridge, then cover the whole thing with Vaseline. So any time I’ve used Vaseline in the dental surgery. Then take the bridge off. Dry the retainers, put my temporary cement on the internal fit surface the intaglio, seat it. And then because it’s covered in Vaseline, all the temporary cement will peel off dead easy. You doubt all those smears everywhere and you don’t have lots into proximally. Clean it up with super floss, then leave the whole thing alone for six weeks. And then you can take your final impressions. You need five to seven days for the epithelium to heal. And you need, well, 21 to 28 days for the connective tissue to heal and mature. So if you leave it for six weeks, you’ve got loads of time. The patient is instructed to clean with super floss. And also, I get them to use waterpicks. That’s really effective. And then six weeks later, you take the whole thing off, take a regular impression, and then they’ll instruct the lab to fit the pontic in the final restoration into the socket you’ve created, but do not scrape the model. There is a bit of a tendency with labs, when they make a bridge, on the stone of the model, or in the CAD, to actually remove a bit of tissue in the pontic sites, so when you seat it at blanches, you don’t want that. Because obviously if it blanches, you’re going to end up with a, basically what’s called a biologic width invasion. You’re going to get inflamed tissue. So that’s it really on the post extraction, which is what most people will deal with. [Jaz]Hey guys, it’s Jaz interfering here with two mega quick announcements. One, if you want this episode summarized in a beautiful infographic with all the decision making and summaries, then head over to protrusive.co.uk/ovate and we will send it to your inbox. So that’s protrusive.co.uk/ovate. For those of you who’ve seen the protrusive infographics before you know, a lot of effort goes into it and they are the best infographics in dentistry. I am pleased to say. The second announcement is for our live event on Saturday, 30th of September. So it’s Occlusion and Communication Symposium 2023. We’ve got some great speakers. The lineup includes Dr. Kostas Karagiannopoulos, who did the injection molding episode for tooth wear many episodes ago. He’ll be talking about how to transfer the wax up to the mouth and make sure the occlusion is respected. We’ve also got Dr. Tif Qureshi talking about DAHL technique versus full mouth rehab. When do you choose which one? Then we’ve got the high flying Dr. Rhona Eskander talking about moving away from single tooth dentistry and all the challenges that comes with being a young dentist and you’re trying to push your boundaries and how you overcome any mindset issues. That’s Rhona. And then we’ve got a live panel, like a fun thing. Me and Mahmoud Ibrahim will host this live panel discussion. We’ll ask some tough questions to these guys as well as open up questions from the audience. And then after lunch, we’ve got Prav Solanki. He’s going to do a 90 minute master class on how to communicate, how to elevate your communication to increase your treatment uptake. Like there’s one thing to be able to do the dentistry, but if you can’t communicate the value of that dentistry to your patient, then you’re not going to be able to serve your patients the best. So it’s a whole communication session with a keynote speaker, if you like, is Prav Solanki. And then we’ve got Salman Pirmohamed. He’s been our guest twice before on the podcast, and he’ll show you some. Full protocol cases. Sometimes it’s nice to see the step by step. Before and afters are good, but I’ve told someone to really show the step by step by step when it comes to these bigger cases, tooth wear, and those that involve occlusion and communicating with the lab. Lastly, we’ve got a drinks reception from 5pm to 6 pm. So we would love for you to join us on Saturday, 30th of September at the Sheraton Skyline Hotel in London Heathrow. The website for that is protrusive.co.uk/occlusion, that’s protrusive.co.uk/occlusion. Now it’s back to Dr. Jason Smithson. I’m trying to still extract as much as I can. He’s so full of knowledge and at the time of recording, I guarantee you I was having so much fun. I hope you guys are too. Before we get to the extraction one and then immediate management, it’s got a few nuanced questions about the protocol you explained. So firstly, thank you for sharing that because very difficult to find information about this. And I think that’s going to be incredibly helpful to all the dentists listening and watching. I appreciate you being so giving with that. With that protocol, I think one bit, if I followed correctly, and just for understanding of it is once you’ve got the- [Jason]Very technical without pictures, isn’t it? [Jaz]I know, I know, which is tricky, but this is why we’re going to elaborate a little bit more. So once you put the composite into the tissues whereby you’ve just drilled the soft tissue away and maybe you draw some bone away and once you’ve controlled the bleeding you put your composite inside so that it’s kind of like a flattish and it’s going into it but at this point I think one thing you didn’t quite make clear which makes sense to me but just to make it super clear, do you want to seat the bridge on as you’re curing, so that the composite then joins onto the pontic of the bridge? [Jason]Yeah, so what you would do is you would, once you’ve got your bridge trimmed to your ideal, then when you add the composite, you would roughen the pontic side a little bit, just with a burr, place a little bit of Signum, place a kind of dome of composite. I tend to use like shades A4 and A5 because it looks a bit root-ish. And then seat the whole thing over the teeth to full seating. Often times you can just get the patient to occlude or press it down. Or in the posterior just get them to occlude on a cotton roll. That fully seats the bridge so the composite is being forced. into the site you’ve created. You will get some excess coming out. A little nuance is actually to use an instrument called an IPCL, Interproximal Carver Long, which is a really skinny flat plastic. And you can actually sculpt off the excess with that, means you’ve got less trimming, and then lye cure it. Is that clear? [Jaz]That’s fantastic. So the bit of actually seating the bridge on at the time of actually having the composite in the tissues. It was a bit to clarify there. And just for clarification. [Jason]Another question would be, why would you use composite rather than acrylic? [Jaz]Okay, yeah, is it because of the heat? [Jason]No, some people don’t. Well, tissues like composite better than acrylic. It’s a more polished surface. And actually, it’s a bit more viscous so it’s easier to control. That’s why I do it. [Jaz]Amazing. Yeah, definitely someone would have asked that on YouTube, why not use acrylics. I’m glad you covered that already. And then when you drew the pencil line, when you have the bridge now seated before you cement it, the pencil line is essentially telling us that is the gingival zenith as we see it basically. And then once you take that off and you send, you then mark 1. 5 millimeters above that line. That’s like your actual ovate part, the pontic, and then beyond that will be the, all the regeneration of the bone and the connective tissue and the epithelium. Is that a fair summary? [Jason]It is. So when it’s seated and cemented, what you’ve got in that area is sometimes exposed bone and then blood clot and then your composite pontic. What’s going to happen over time is that blood clot is going to form connective tissue and epithelium and heal from the base. Now, if you don’t trim it correctly, you’re going to basically have your composite on bone and then there’s no room for that blood clot to convert into connective tissue and epithelium. That’s why you’ve got to be super careful with that. [Jaz]Brilliant. And so that explains it all really nicely. In this scenario that you explained is whereby, yes, the tooth was extracted a long time ago and then you describe exactly how you modify it and that was all well explained. But this works when you want to migrate your gingival zenith. Apically, what about if you’re missing lots of tissue and actually you’d want to bring some tissue down, are we then, this is something I know nothing about Jason, but like, are we looking at connected tissue grafts? How stable is that? Is that something that you do with a periodontist or yourself? [Jason]Alright. So, bone defects are classified into three classifications called Seibert classification. Okay. So class 1 is a buccolingual defect. So in other words, the ridge is a bit thin, but you haven’t lost height. [Jaz]So this is like when someone’s done an extraction and the labial plate broke off, right? [Jason]Yeah. Or the patient just lost tissue, hardened the soft tissue. So class 1, buccolingual’s thin, but the height coronoapical is correct. Okay. Class 2 is when the buccolingual is the correct thickness, but you’ve lost height, right? So, you’ve lost coronal height. And class 3 is you’ve lost buccolingual and height. Okay? Ovate pontic without any graft only works well in class 1. So when you’ve lost width, in other words, buccolingual thickness. If you’ve lost height, it’s more challenging because there’s nothing to play with, right? Now, oftentimes, if you’ve lost buccolingual thickness, often you can get away with just an ovate pontic without any graft. So in a class one, you can do an overweight pontic without any graft a lot of the time. If you’ve lost a lot of buccolingual thickness, you may need to consider a graft, but in a class 1 defect, you can usually get away with just a soft tissue graft. In other words, you’re grafting connective tissue typically, usually to the buccal, to generate enough width to create your ovate pontic. For class 2 and class 3, you always need to consider hard tissue and soft tissue graft. So for the purposes of this podcast, I would suggest that that’s referred out, because that’s a specialist job generally. In terms of class one, with a soft tissue graft, we probably haven’t got enough time to talk about this, but it can be done in a number of ways. You can either take the connective tissue as what’s called an allograft. In other words, it comes out of a pack kit. And I used to do a lot of cases with a product called Alloderm. You can’t buy it in the UK anymore. It just comes out of a packet, you roll it up into a sausage shape, you make a little kind of slash incision on a gingiva, undermine it, and then you put this sausage shape bit of material in, you kind of tie your sausage shape up with resolvable sutures, a bit like tying a pork joint, if you’ve ever seen a pork joint, and you just put that in. And I used to tend to suture that to the palatal side and then I tended to over bulk it so that when I made my ovate pontic, it got squidged interproximally and I got some papillae out of it. Alloderm is not available now. There are other, allograft materials on the market can still do that. Nowadays I tend to use a patient. So you can either take that from the palate with a procedure called a subepithelial connective tissue graft, or, and this is what I do quite commonly, I take it from the tuberosity. Oftentimes, if you take, if you can imagine a wedge of tissue from the tuberosity. With the wider bit of the wedge being the epithelium and the more apex, the triangular bit of the wedge deeper into the connective tissue, I just, if they’ve got a really flabby tuberosity, you can just harvest that, trim off the epithelium, then close the tuberosity, couple of sutures, and then you can do the same thing as I used to do with the Alloderm graft in the anterior, just with this thick bit of tissue. And the advantage is, it’s a little bit more friendly to the patient because it’s actually them. And you haven’t got the hang up of it being, it comes from who knows where. And it’s cheaper for the patient because I can harvest one of those in, I don’t know, 15 minutes. And you haven’t got the cost of the allograft. So that’s how we deal with that, with a graft or whatever. [Jaz]I mean, because that is very specious and we could spend a whole five hours talking about that. I think the only question I have here. It’s actually something from the community. I wasn’t safe for later, but someone actually just asked like, how can we learn the soft tissue skills that Jason has? So is there any way that you recommend to learn? [Jason]I wouldn’t recommend learning my skills because I’m not the best surgeon. I very rarely post cases of my surgery. I usually post like, before and after, and I never post in between, because my surgery usually ends up looking good at the end, because I understand biology, but I’m not the most refined surgeon, I’ll be very honest with you, I’m a little bit on the agricultural side of surgery. So I know what I’m doing, but it never looks very pretty. So I think, there are a number of people who teach surgery to a good standard. I think frankly, and no disrespect to English periodontists or UK periodontists, but really, really, you’ve got to go abroad to learn periosurgery and grafting to a high standard. And I learned quite a lot from Zuhr and Hürzeler in Germany, and then there are a number of people in the U. S. who are very skilled in the- [Jaz]I just thought I’d pick your brain on that, and it’s good that we know that where you learnt your stuff for a result, and it was nice to hear, Jason, because we see you as, like, this, like, you’re just good at everything, so it’s nice to see you say that, actually. [Jason]No, I’m really not. Yeah. [Jaz]Yeah, it’s really nice to hear that, so thank you so much for sharing that, it made us all feel good. Jason, let’s talk about that other pathway now, whereby you’ve just taken out a lateral incisor, let’s say, and you want to use that as a way to develop an ovate pontic for there. That protocol is going to be way different. How do you manage it? [Jason]A bit different. I mean, the first thing you said was a lateral incisor. And actually, I would just like to get to segue into a lateral incisor in my practice is almost certainly going to be a pontic every single time. I very rarely replace a lateral incisor with an implant. Because they typically, there’s oftentimes not enough room for the implant. And secondly, they always look rubbish. And they often look a lot better as a pontic, be it an adhesive bridge, a conventional bridge. or an implant retained bridge. So there’s that. Now, how do we manage from extraction? Well, these are the cases that where the temporary has got to stay on for a decent amount of time, three to six months. So I would first of all get a lab made bridge, temporary bridge. Made before you start or a provisional venture. So you would prep the teeth, assuming we’re doing a conventional bridge. We can talk about adhesive bridges later on, if you want. You’ll prep the teeth. I would tend to prep the teeth to a good standard before I extract the tooth, because otherwise you end up decorating your whole office with blood. Alrighty. Then, I would extract the tooth. Now, it’s important to extract the tooth. There’s a saying of, there’s a kind of phrase, atraumatic extraction, which I think is kind of an oxymoron, because like, how can you atraumatically extract a tooth? But let’s call it “extract the tooth with the least carnage possible”, preserving as much soft tissue and bone as you can. So what I typically will do is go around the gingival margin with a scalpel blade, 15C usually, right down to bone, so I’m not going to tear the tissue. And then I’m going to use really, really fine sharp periosteal elevators and just work my way down with a periosteal elevator. Just go all the way around the tooth. And if you take your time, you can often find as you’re working with wider and wider periosteal elevators, the tooth will just rise out of the socket. And you’ll almost be able to pick it out with your finger, or take, and if you’re having to lean on it with forceps, it’s just really a bad idea because you’re going to end up bending or fracturing the plates, and then you’re stuffed. Then what you do is pretty much the same as you would do post extraction, but obviously you’ve got your defect created for you by virtue of extracting the tooth in any case. Now, the next question is, how far do you take the composite addition into the extraction socket? My suggestion, there is some nuance to this and we can talk about this later on if you want, but to be safe. I would take it three millimeters in first of all, three. So what you do is exactly the same thing. Signum onto the base of the pontic bit of composite resin. Take it into the extraction socket. Clean it up with an IPCL. I often sometimes use a number three brush, as well as some modelling resin, just to smooth it. Light cure it. Mark the position of the gingival margin. Take it out. Trim it back so it’s in three millimetres. Cement it. Then, I would typically leave that alone for about six weeks. And then after six, there’s no good data on this, by the way, after it’s just kind of, this just was worth the years. After six weeks, I would take the thing off and I would shorten it to two millimeters. And then after 12 weeks, I would take the thing off and shorten it to 1 millimeter. Now, there are some nuances. If the patient, what you need to look at is your relative risk of losing tissue and creating a Seibert class 1, 2, or 3 defect. Now, obviously, if the patient has very little bones surrounding that tooth buccally, for example, they’re a periopatient. They’ve lost tooth, they’ve lost tissue, bone tissue, as a result of a periodontal disease. Or perhaps there’s a root fracture, and they’ve lost bone as a result of that. Or a perforation, or something like that. When you take the tooth out, you’ve lost a lot of buccal bone. So, your risk of the whole thing collapsing is quite high. So, in those cases, I might leave it, after my second adjustment, I might leave the whole thing one and a half, two millimetres into the tissue, rather than shortening it to a millimetre, because otherwise the whole thing’s going to collapse in. You’ve got to temper that with a patient’s ability to clean it. So if they’re a periopatient, and they’ve lost tissue as a result of periodontal disease, and their oral hydrogen is immaculate now, you might want to leave a couple of millimetres in. If it’s not so brilliant, you might want to take it a millimeter and take the risk. It’s difficult, and there’s no hard and fast rules there. [Jaz]And in terms of the healing there, Jason, I suppose the biological width just re established itself based on the most apical extent of the ovate pontic, and it just heals around it. And so there’s no preparation needed because the defect is there and just heals around the pontic and the biology sort of sets itself? [Jason]Yes, except in patients that are Kois, who K-O-I-S, who originally described bone sounding, which I kind of talked at about earlier on to some degree, actually describes people as being high bone crest, medium bone crest, or low bone crest? What that means is how the bone relates to the cemento enamel junction of the tooth. People whose bone is close to the cemento enamel junction, in other words, have very short biological widths, are high bone crest, and people whose bone is a long way from the cemento enamel junction are low bone crest, and most of us are somewhere in between. In the patients with high bone crest, you’ve maybe got to consider, because they’re at low risk of losing tissue. Does that make sense? [Jaz]Yep, they’ve got plenty of bone, healing capacity, and yeah, more tissue. [Jason]And the bone is super high. So those patients, you might only want to tuck it in a millimeter, and you’re at very low risk of losing a ton of tissue. People with low bone crest are at super high risk of losing a tonne of tissue, so they’ve got to be managed slightly differently. So, there are a lot of, and then you’ve got the medical contraindications, and then you’ve got, in terms of their healing, and then you’ve also got to think about their biotype, the thickness of the tissue itself. Some people have thick biotype, super thick tissue. Some people have thin biotype, really thin tissue, and it’s usually related to the thickness of the connective tissue rather than the epithelium. And you can get away with quite a lot with people with thick biotype, and you will, sometimes, you can do everything perfectly, and it doesn’t come out quite so well in people with thin biotype, just because their biotype is quite challenging to deal with. So these are all other factors that you’ve got to factor in, but what I’m trying to do over this very short podcast is to just give a feel for a general approach, really. [Jaz]Yeah, yeah. It’s impossible to cover every single case, and it’s also case dependent, and so many biological biotype variables. But just on that, like, does the thick or thin biotype, how could that influence how deep the ovate pontic goes? Can that influence whether it goes a millimeter or more towards the two-millimeter mark? [Jason]So, now we’re getting into super nuance now. I mean, if you bone sound generally around their mouth and you’re seeing thicknesses of like four millimeters, and you only put three millimeters for your pontic side. [Jaz]That could be an issue. [Jason]It could be. Do you see where I’m going with that? [Jaz]Yeah. Yeah. [Jason]All right. So, this is where it gets into really. I hesitate to talk about this broadly on a podcast because what I want to do is for people to go away and do specialist procedures that people have spent five years training to do and probably 20 years learning it and have problems. [Jaz]Very valid. And I think, this would be a good point to just finally conclude and say can you tell us about the E pontic and how may perhaps you’ve already describe it? How does the E pontic differ to what you’ve said so far? [Jason]Alright, so the E pontic was first described in 2015 by a guy called Korman, an American, as in, if you want to read about it, I think it’s, a Journal of Esthetic and Restorative Dentistry, JERD. Alright, so, your ovate pontic is a bullet shape, and your E pontic, and it penetrates a millimetre to a millimetre and a half into the tissue. The epontic is completely different. The epontic, rather than being a bullet shape, is, on the facial surface, it is flat. From mesial to distal. And the flat aspect penetrates a millimetre subgingival. And on the mesial and distal, rather than it being a dome, it’s a right angle. So it’s very square. And then on a palatal surface where an ovate pontic penetrates a millimeter on the palatal of the E pontic, it rests at the level of the gingival margin. So what you’ve got is this straight, flat surface coming up like that. This being facial and this being palatal, this being a millimeter sub G, this being super flat. Because it’s flat, it’s still cleansable with superfloss. But the concept is that because you’ve got a right angle mesially and distally, it supports the papilla more. So the thoughts are, the general, in Korman’s paper, he describes the fact that he feels that the stability, certainly papilla wise, is much more stable with the epontic rather than with the ovate. Nobody’s actually done a prospective trial on that comparing one with the other. So we don’t really know. What I would say is, in my practice, if somebody has thick biotype and I create my pontic at the time of extraction, I’m probably going to go ovate because it’s a little bit easier and my relative risk in terms of their biology is quite low. If I’m doing post extraction and they’ve got thin biotype, and I can’t change the biotype if they’re not prepared to have a graft, either they don’t want it or they’re not prepared to pay for it, so I can’t change their biology, I might go E pontic, because they’ve got a better chance for papillostability. Again, this is very much based on, on experience and a knowledge of biology. For anybody listening, I think it’s worthwhile reading all those boring papers and boring books about tissue biology, because you can’t do this predictably unless you’ve got a good idea of biology, and that’s really the key and it’s something we skip nowadays. It’s kind of tedious, but yeah. [Jaz]But it was great for you to introduce the E pontic. I’ll put some visuals there as well. And I will put the paper in the show notes that you mentioned as well. I think that’d be useful for people to go in. This said, consider this like a introduction to it. I had final two bits left, Jason of the spot. Really good out of interest- [Jason]Just out of interest for papers while we’re here. There’s a really good paper, I can’t remember the journal, but it was written last year in 2022 by a guy called Bill Robbins. You may have seen Robbins’ Operative Dentistry textbook. He’s a super nice guy. I met him at the Restorative Dentistry Congress in February. Yeah, Bill Robbins paper on ovate pontic last year was, it was super good, a really good overview. [Jaz]Excellent. [Jason]I’ll send it to you in a moment. [Jaz]Yeah, no, definitely. I’ll attach that to the show notes. So thanks so much. And with full credit to Dr. Robbins, that’s amazing. My final two bits is, Professor Robbins, that’s Professor Robbins to you all. Okay, fine, good. So that’s amazing. And I’ll add that. So thanks for sharing that. Final two bits is, any tips on lab communication? And the final bit is, I’m going to tell you the dodgy GDP way that I’ve done it, and I had pretty good results, but you can feel free to critique it and tell me where I’m taking the risks. I know where I’m taking the risk, but you can critique me on the things that I could be doing differently. But I’m, yeah, saving time. So, but anyway, any lab tips that you want to give? [Jason]Alright, so you got lab tips in terms of the provisional, and lab tips in terms of the final. The provisional, I would ask them to create the ovate pontic in the model. So that when you make your lab provisional, the gingival margin and the zenith are in the correct position right from the get-go, which is going to save you a lot of trimming and mucking about. So that’s the first thing. They can either do that with a scalpel or my lab just do it with an acrylic bur. They create the pontic site with the acrylic bur, put it where I want it. I could, I can mark it on the model with a pencil if I want, or we can mark it digitally. And then that’s that done. In terms of the final, there’s not much lab instruction, other than the fact that you don’t want to scrape the model, which we mentioned earlier, which they’re oftentimes really tempted to do. The other thing is, and I mean most of my bridge work nowadays, is zirconia. Now, if you look at the studies, tissue likes zirconia more than it likes ceramic. So, if you get the lab to create the superstructure, the framework of your zirconia bridge, that fits precisely into your ovate pontic, so that your pontic site, which is sub g, is entirely in zirconia and is not layered or give you a better tissue is more tissue friendly now. Obviously, you’ve got to hide that. So there is a product, it’s essentially a powder-based tint, which labs use called Miyo, M-I-Y-O. And they can use that tint, the zirconia, so it would appear like it’s a root. And that’s how we deal with, obviously we don’t tint the fit surface, just a bit, maybe half a millimeter out, and then you get the look of ceramic, but with the business end, let’s say in the zirconia, so that will give you a better outcome. And I don’t really think about that because my lab does that now because we’ve been through it, but it’s worth telling them initially when you start working with them. [Jaz]Okay. Brilliant. And I didn’t know about this Miyos. That’s great to be given a lot in this podcast episode. Thank you. [Jason]Miyos, brilliant. Miyos. Yeah. [Jaz]Never heard of it. [Jason]We used Miyo on Emax. Now, we don’t really do that many layered Emax. We just stain and glazes it and we stain and glaze zirconia. We don’t layer that. So the lab love it because it’s way quicker, better workflow, and I’ve got a stronger restoration. [Jaz]Amazing product. Brilliant. I look, I look into that. I mean, it may be the lab’s already using it, I don’t know, but it’s good to the name of mine, probably not, which is good. Yeah. Yeah. Fine. Well, I’ll speak to my tech technician. So, lastly, here’s how I’ve managed ovate pontics before when I wanted to cheat a little bit and skip the time for all the healing yeah, I know you’re going to hate me for it. [Jason]And I hate you already. [Jaz]I know you’d never do this but here’s my hack that I managed to do so if I’ve done my bone sounding and let’s say I’ve got five millimeters my bone sounding and I’ve decided that I’m happy to go to a two one point five two millimeter pontic. What I will do is let’s say for a resin bonded bridge I will send my scan, or usually for me it’s a scan, and I will tell my technician. I’m going to go for an ovate pontic. I want you to actually create the ovate site for me. I want you to go in 1. 5 millimeters and either I’ll check it when they send me a WhatsApp and I’ll have a look to make sure they’ve gone in. Now, when the bridge comes back, let’s say it’s a resin bonded bridge. It’s not going to fit because there’s tissue in the way. At this point, Jason, I’m going to get my thermacut bur, right, and just do it away until I can passively seat my bridge and there’s no more blanching. Now, I only do this in cases where there’s plenty of decent thickness of tissue and I wouldn’t do it in an overly aesthetic case on a young patient whereby I really want control, like crazy control over it. But that’s how I’ve cheated before. Am I really naughty? [Jason]All right. So the technique you’ve just described is actually in Bill Robbins’s paper that I recommended earlier. Right? So, it’s not too naughty. All right? The things I would say about that, I don’t think it’s a terrible solution and actually it is possibly a very acceptable solution for posterior units. All right? So, there’s that. In the anterior, I would suggest, it’s been my experience, it’s very, very rare to find that kind of patient with that much tissue in the anterior. It’s quite unlikely. So, that’s one point. The second point is, certainly, if you’re doing an adhesive bridge, even with a thermacut bur, you’re going to have some blood, so you’ve got a complication of your bonding. So that’s true. And the second, and the third complication is that your healing will be unpredictable. Most likely, you will get away with it to what’s called an acceptable level. But you’ve got a reasonable chance of tissue collapse, and you’ve got a reasonable chance of loss of papilla, or your prosthetic didn’t fill in the papilla in any case. So I would suggest in the anterior, in the unlikely event that you’ve got enough tissue, it wouldn’t be a bad approach if you’ve got a patient. with low to moderate aesthetic demands. I would say suicidal in somebody with high aesthetic demands. [Jaz]Absolutely. [Jason]I’m not going to be, I’m not going to sit here and be ivory tower snobbish about it because I don’t think it’s a terrible approach. I just think it introduces some risks. [Jaz]Oh, yeah, there’s a lot more, it’s less predictable, for sure. And if you want predictability, you have to, there’s no shortcut here. I mean, I propose a shortcut, but then you’re sacrificing predictability for the shortcut. So, yeah. And then you’ve summarized it. [Jason]I think posterior units is, it’s not the worst idea. And actually you’re more likely to have the tissue in posterior units. [Jaz]Amazing. Jason, you’ve covered all the questions that I had and given so much value here, as you always do, Jason. We appreciate it. You’ve taught me a lot on your course for onlays way back when many years ago, vertical preparations. I’ve never actually attended your resin course, but everyone raves about them. Please tell us, I know you’re doing so much teaching in America here. What are the kind of courses that you’re running nowadays? [Jason]In the UK or the US or elsewhere? [Jaz]‘Cause we’ve got a 30% of the audience in the US now. So, I think the American dentist would love to know and also the UK dentist. And I encourage the UK dentist to go and do a little CPD tour around the world as well. So acceptable. [Jason]So in the US with the exclusion of some podium lectures, I’m, my hands on is pretty much at Spear. So I, I’m resident faculty at Spear Education, which is in Scottsdale, in Arizona, near Phoenix. Nice location. If you want a sunny holiday, it’s a lovely place. Nice hotels, nice restaurants, good bars. Second to none facility with really good support. We’ve run a three-day hands-on course there. So, it’s three days of probably about 30% lecture, but the vast majority is hands on, and we cover class four, class one, class two, resin veneers, discolored tooth, peg lateral, diastema closure, and worn teeth. And the interesting thing about that course at SPEAR, which is called Excellence in Composite Restorations, which is unique as far as I’m aware in the world, is that it’s not sponsored by one composite company. So what I’ve done is I’ve chosen four different composite companies. And the reason why I chose those four is really because their composite systems are all completely different. In terms of application, so you get the chance to try four different approaches to the same thing. And it’s not kind of sales heavy, which I hate. And I’ve also created in that what I call a translation sheet. So there is, say I use, for example, I don’t know, Ivoclar’s enamel which we do on that course. There’s a little translation sheet so you can look at that and then you can translate it to, for example, Tokuyama or Kuraray or GC or whatever. So you can basically do that class with the four different composites and if you like one of those composites you could buy that or you could translate it to the composite you’ve already got in your own practice and just carry on doing the same thing on Monday. So that’s that course. The other hands on classes I do. Regularly there’s one in Australia next year with the Australian Dental Association, which I do regularly in Sydney and Brisbane, although we’re doing Melbourne next year. [Jaz]I’ve got loads of Aussies who listen to the podcast, so please just send me those links like just nice and easy place on the YouTube and on the blog page and the app just people to click on because it just makes it easier for everyone. But yeah, please do. [Jason]In the UK, yeah, I’m just in talks about doing something in England, but currently my main base is in, well, for the foreseeable future, my main base is in Glasgow, and we have a website called restorativeprogramme.co.uk, programme, double M, E, and we have a class which is Resin in September, which is sold out. Sorry, and we also have a hands-on class in December, which I think there are spaces available on, which is Ceramic. So, in that class, we cover Ceramic Restoration. We basically prep a full upper arch, and we do onlays, we do onlays with margin elevation, we do partial onlays. We do crown preparations on posterior, on anterior teeth. We do veneer preparations on anterior teeth, three different types of veneers. And we do crowns with vertical margins. And we also do the pontics, which we’ve discussed today. That class is again, fairly unique, I don’t, I wouldn’t say it’s totally unique, but I think it’s relatively unique for the UK in so much as it’s three days, three seven-hour days, entirely hands on. The lectures are done by webinar, so the lectures are all prerecorded, so you get the lectures, basically you get the lectures when you sign up, most people get them a month or two prior. You watch the lectures, hopefully, and then you turn up and just do hands on and you also get the opportunity to watch the lectures for six months afterwards with online support. So basically, you get three days out of the practice and 46 hours of CPD. So you’re done for the year. [Jaz]Wow. Okay. And this is how all courses should be, in my opinion, or a theory bit that you can learn at home. You can. So I respect that you guys do that already. That’s awesome. [Jason]Yeah. Cause I was looking at that and I was like, well. If I wanted to take time away from my family and time away from home and time out of the practice and the cost of travel and the cost of a hotel, I don’t want to be sitting in a lecture hall listening to a lecture when I can listen to it online. And also, the fact is, if you listen to it in a lecture, you miss a bit. You have to go to the bathroom and take a phone call or you missed it. And you’re asking a question while everybody tuts and sighs in the room, it’s already been covered. Whereas if you’ve got it on a webinar and you think, oh, I didn’t quite get that. You just rewind it, watch it. Yeah. Watch it even twice. So we commonly get people watching it. Two or three times. So that, I think that’s the future of education, really. Webinars watched at home and hands on done live. Blended, blended program. Yeah. Jaz’s Outro:Amazing. Jason, please do send me those links so I can put them on. And if you got, Professor Robbin’s paper, that’d be amazing as well. I’ll find the 2015 E pontic but if you have it handy, go for it. But if not, I’ll find that. And I’ll stick in the show notes. Thank you so much. Honestly, it was absolutely brilliant. Well, there we have it guys. Isn’t that the best resource on ovate pontics you’ve ever seen? If it is, I would appreciate a comment or a thumbs up to show some gratitude to Dr. Jason Smithson. I put all his links at the bottom. He’s a great clinician to learn from. I would heavily recommend going on his courses, go to his courses in America. Right. If you’re in Europe, go to America, have a tax-deductible break and learn from Smithson and all the other educators in America. And for those of you on the app, you can answer a few questions, get some CPD. You’ve made it this far. You deserve some CPD. Thanks again for listening all the way to the end, and for those of you who heard the announcement about the event on Saturday 30th of September in Sheraton Skyline Hotel, we’d love to see you there. The website again is protrusive.co.uk/occlusion. Otherwise, I hope you enjoyed this episode. I’ll catch you in the next one.

Welcome back to part two of this ‘Restoring the Single Implant Crown’ podcast series that’s about to kick start your implant career. We’ve teamed up with the uber-knowledgeable Dr. Devang Patel, a dental wizard with over 13 years of spellbinding experience under his belt. Leading on from the previous episode that focussed on case assessment to impression taking/digital scanning, we now cover the step by step protocol for fitting the implant crown, maintenance, and troubleshooting. https://youtu.be/FDB72GtYAAs Watch PDP157 on Youtube Dr. Patel’s got your back (or should we say teeth?) every step of the way! Check out his social media platforms for further information about his upcoming implant restoration course: @dr_devangpatel info@drdevangpatel.com www.drdevangpatel.com Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode:00:00 Intro01:12 Restoring Implant Crowns Infographic02:03 Recap Part 103:45 Inspecting the labwork05:52 Assessing the occlusion06:22 Keeping the implant clean during the fit appointment07:21 Anaesthetic Prior to Implant Crown Try-In?08:20 Screwing in the crown11:13 Occlusion and guidance17:18 Temporarily restoring the access hole18:33 Review19:49 Definitive torque and sealing the access hole25:46 Yearly review of Implant Crown27:18 Radiographs29:21 Excessive blanching when fitting crown31:21 High occlusion management32:06 Open contact points for implant crowns34:43 Other implantologists’ work38:29 Angulated screw channels43:24 Loose implant crowns45:52 Implant passports46:57 Adjusting the occlusion48:24 Dr. Devang Patel51:13 Outro You can now download the infographic that sums up Part 1 and Part 2 of An Idiot’s Guide to Restoring Single Implant Crowns. Just head to protrusive.co.uk/idiot If you liked this episode, you will also like Full Mouth Rehabs Part 3 Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month? Click below for full episode transcript: Jaz's Introduction: Hello, Protruserati. I'm Jaz Gulati and welcome back to Part Two of an Idiot's Guide to Restoring the Single Implant Crown. Now, if you haven't yet listened to the first part of this episode, that's PDP156. Jaz’s Introduction:You should probably start there first because Dr. Devang Patel, our esteemed guest, he talks us through from the very beginning, like how do you assess the site that might be suitable for an implant and what to actually do if someone else’s placed implant is coming to you for the restoration. And let me tell you, I learned so much. The episode is called an Idiot’s Guide. I’m the idiot, right? So I was learning so much as getting along. He taught us about internal hex, external hex, conical, or butt joints, all these things I was learning about implants. Then we talk about impressions and scanning. And now we’re going to be talking about what happens when the lab work comes back from the lab and you’re going to assess it. You want to take a radiograph. You’re going to actually screw the screw retain crown in. But what are you checking for? Do you have to give local anesthetic, for example? How much talk do you need to give at that point? How do you then restore the screw access hole? And what should be the follow up protocol going forward, as well as the all important troubleshooting? It’s really important when you learn a new skill, that you learn about the troubleshooting. So any of the common complications that you can get ahead of it. Protrusive Dental PearlSo just before we go and join Devang for that Part two, I’m going to give you the Protrusive Dental Pearl. It’s basically a summary of both these two episodes, so PDP156 and this episode, because I imagine as a learner, it can become quite overwhelming, especially if you’re commuting, chopping onions, and then to try and remember and think, you need like an aid memoir. I know the premium notes are there. But this is like a step-by-step appointment by appointment summary, which I will make available. So if you’re a premium subscriber, you will find it in the app already, but if you’re not, and you’d like to get your hands on this appointment by appointment checklist, if you’d like based on everything that Devang is teaching, then all you have to do is go to protrusive.co.uk/idiot. That’s right. It’s protrusive.co.uk/idiot. And I’ll take you to the landing page so I can email you the PDF. Thank you to Devang for helping us make this so we can make this confusing topic tangible for you. Let’s now join Devang for the main episode and I’ll catch you in the outro. Main Episode:Welcome back again Devang. We covered last time about restoring implants and there was so much to it that we split it into a two-part episode. Just briefly remind us the three steps that we covered so far and what step four is today and the journey you’re going to take us on today. [Devang]Okay. So thank you very much Jaz for having me again. So it’s always delighted to come to your podcast. In step one, we discussed about how to do clinical assessment for the implant restorations. We discussed how to record impression, how to take a impression for implants. And we mainly discussed how to communicate with the laboratory, what to write in the lab docket, because if you are really taking digital impression for implant, it’s quite easy, very straightforward. You just need to put the scan body in, scan it like you normally do. But it’s the communication with the lab and you need to be a little bit in control as to how labs are making the restoration. Are they using Ti bases, which is off-the-shelf abutment and then cementing crown on top, because that’s the cheapest way to do it. So if your lab cost is really low, that’s how your lab is doing the crowns. And nothing wrong with it, but many time Ti bases are very very small and there is a risk of their crown decementing even though you have a screw retained crown. Because lab would make the crown in the lab, create a hole through the crown and cement it onto the abutment. You can gain access to the screw really. So you need to be aware of that. And now in today’s episode, we’re going to discuss about step number four, which is Fitting of the Crown, step number five, which is Maintenance. And we’ll discuss some of the complications because when you start doing everything, everything’s going fine. That’s great. But really, you understand your depth of knowledge when something doesn’t go right, and you need to correct it. [Jaz]Great. Well, if you pick up from the point where you sent your scan body or impression to lab, you put the healing abutment back on. A few weeks later, you’ve done your lab communication, the patient comes back, and you’re now going to remove the healing abutment? Or what are the procedures, checking lab work? You take it whichever direction you want, sir. [Devang]Okay, so, first of all, when the lab work comes in, I would check, make sure that on the model, the crown looks fine, okay? So, make sure that you check it on the model, what you need to do is when the model comes back, most of the time it will come up with a gum attached to the, you have a fake gum on the model, it would be there. I take the gum off and then put the crown in on the model. Check, make sure the crown seat’s okay. The other thing you need to do that is that you need to have, or you need to ask your lab to get you a new screw. You don’t want to use the same screw which lab used in this lab to tighten patient’s mouth because the screw have gone in and out multiple times and it’s not ideal. So you want to use, maybe you can use the same screw to try in the crown and make sure everything’s fine before you use, but finally, right at the end, you want to use a fresh new screw to screw the crown in. So you’re going to check everything on the model, make sure the contacts are not tied. [Jaz]Devang, is this standard protocol or is this you being like extra careful? Is this like what is standardly taught and practiced? [Devang]This is how I was taught when I was taught, implant restoration at Eastman. That’s how I was taught. I know it’s not a standard protocol in the sense that I know most of the technician will not send you a new screw. You do need to request for it. I have actually, I’ve just bought the screw from the company itself because it’s cheaper for me to buy it that way. So, I buy it on bulk, like 50 screws. They’re not very expensive. If you buy 25 BioHorizons screws, they are like 80 pounds, 85 pounds. So it’s not tremendously expensive. So I just buy it. I have it with me and the technician will send me the crown and I’ll change it myself. It’s a recommended protocol- [Jaz]Good point. [Devang]And that’s how I was taught, but I don’t think that’s a commonly used protocol, if that makes sense. But it won’t add too much to your lab costs. [Jaz]A nice little tip and a pearl for those implant dentists. [Devang]Now, once you assessed on the model that everything fits fine, now you’re going back to patient’s mouth. So patient come in, you are doing the same protocol like you do for normal cementation of the crown, right? So you’re going to check. Before you even put the crown in the mouth, you’re going to check shim stock holes. You’re going to check the occlusion before you put the implant crown in the mouth. So you’re going to really assess patient’s current occlusion, which we don’t want to change after we place the implant. Once we assess that, we take the healing abutment out. Any time I put, or I take things out from the implant screw on screw, I would irrigate using chlorhexidine because you don’t want to really push any bacteria into the implant, into that channel, screw channel when you’re pushing the crown back in. So even like during the appointment, if I take the crown in and out, patients close their mouth, I would always irrigate with the chlorhexidine. So my protocol is anything, every time I take the crown to patient’s mouth, I would irrigate before with chlorhexidine. Again, it’s a little bit OCD, but I know Khoury, I learned it from Khoury where he would put antibacterial sort of a gel or antibacterial sort of a paste in the screw channel just because he was worried that there could be infection leading or bacteria leading from the screw access channel to the implant causing bone loss. So, again, what was the study behind it? Not much, there is not much evidence behind it. But we want to make sure that we don’t really push any bacteria in there. So then I’ll take the healing abutment out. [Jaz]That makes sense. Now, just a bit more, a step back, actually. How often would you be anesthetizing these patients? Would you have to ever give LA? [Devang]Oh, well, good question, actually. So when patients come in, I tell patient that around 60% of the patients, 70% of the patient can get away without any injection. Would you want me to give you injection or you want to see how things go? While I’m doing the treatment, fitting the crown in, if it’s painful, you can stop me and I can give you injection then. Or I can give you injection from beforehand. Some of the patients, if they are really anxious, they’re like, no, just give me injection. So I’ll give them injection, which is fine. Some of the patients, they don’t like the numbness and they will be saying like, okay, we don’t want to. So I don’t. Generally, when I do the crown, I don’t really compress the gum too much. So my instruction generally to the technician would be, I want a narrow emergence profile. So compression to the gum is not excessive, so I would generally, it’s okay for my patients, but yes, I do give patient an option that whether they want LA or not. [Jaz]Okay. [Devang]So once that’s done, so I would take the crown to patient’s mouth. And generally, when you put the crown in, it should slot in unless you’re using very old type implants or it’s a different implant, like the name of the implant, it’ll come to me, but where there is no connection, you literally, it’s a friction fit connection where there is no hex or anything like that. But generally, most of the implant would have some sort of a hex where you would, you will feel the crown slotting in. When that happens, yeah, conical connection or it could be a butt joint connection, but either or any internal connection will have an internal hex in there. So the crown will feel going in unless your crown is really compressing the gum a lot, that time you might not feel the connection. But generally, you will feel the connection, you will slot it in. And then start screwing the screw in. As soon as you feel the first resistance, you need to stop. And you need to check the contact point. Because what will happen is, if you’re taking a general, normal impressions, open tray or closed tray impression, you are, there is a small chance always that, during the process, the impression post moved a little bit, and the crown might not be in the really exact position. So, if the contact point is a bit tight, Then you could just keep screwing it in and you will use a cross thread the screws and you ruin the screw threads. So you want to make sure you first resist and you check the contact points. If the contact points are fine then you carry on because it may be just compressing the gum and the gum is sort of giving that resistance if that makes sense. So you would keep doing it. [Jaz]It’s just normal checking with floss, right? Nothing more to it? [Devang]Yeah. No, just floss and you checking that floss goes in nicely. With implants I’m slightly more sensitive So if the floss goes in but with the bit more pressure, I don’t like that. So I want it with the gentle pressure floss should go in click click. So you should feel still here or feel the clicking but I want that to be lighter because with the screw-it-in crown you never know, the crown might be compressing a bit, little bit too much and it may not seat completely and you won’t know because floss will still go in because the crown’s nice and smooth. Generally, technician make the crown with the small point contact rather than surface contact interproximately. So it’s easy to just go through that even though they are quite tight. So I would, I would do that and keep checking going back and forth, back and forth, back and forth until I know the crown’s completely seated, the screwdriver’s not turning more and contact points are fine. Only then I would really check occlusion. Okay. So I’ll need to make sure the crown and this is the same thing with the normal crown fitting, right? So you want to make sure the interproximal is fine before you start checking the margin or occlusion, really. So I’ll come to that occlusion in a minute. So I’ll check occlusion. Everything’s fine. Then I’ll take a radiograph to make sure that the crown’s seated properly on the implant. I’ll come back to the occlusion that with regards to occlusion, if you think that the occlusion is quite high, which you weren’t expecting, then you take a radiograph first, because it could be there is something not allowing the implant to seat properly, implant crown to seat properly in the implant, you take half an hour adjusting occlusion, and then you think, oh, the crown is not seated properly, and then you have to send it back anyway to the lab. So make sure that if you think that it’s way off, then check the radiograph first, before you check the occlusion. Now, with regards to occlusion, we want our implant to be 30 micron off occlusion in the sense that you don’t when patient closing. You want 30 micron space between implant and opposing tooth, okay? [Jaz]Clearance. [Devang]Yeah, that’s because obviously we know that our PDL, the teeth have PDL ligament, and then, you know, when patient closes and grinds, they intrude the natural teeth, but the implants don’t intrude. So because of that, we want to give some sort of a cushion effect, some sort of a leeway when patient bite really hard, then all the teeth will intrude and then implant will be very small in contact, very tiny bit. And one of the easiest way to measure that is to, I use articulating paper which is around 12 to 14 micron thick. So, I just double the articulating paper and then ask patient to close and check the occlusion that way. So, make sure that you have 30 micron clearance. Now, guidance is another thing you may need to really consider when it comes to occlusion, whether you’re going to use your implant for the guidance or not. For a single tooth, I will never put guidance on my implant because you can get away with most of the things. So let’s say if your implant is upper right one, you have rest of the anterior teeth, do you use a protrusive guidance? If your implant is upper right three and you prefer, you can’t use canine guidance because it’s your implant. Then you can use a group function. I’m not really too faffed about using group function. Obviously I like canine guidance because it’s easy, but if I have to use a group function, I would use group function. So I would avoid for single implants anyway, my guidance. Now, if you’re doing small bridges and if you cannot avoid guidance, then you need to spread it, spread it out. As much as possible, because I’m doing a full arch implant now, I can’t really avoid guidance on full arch implant. So you need to spread your guidance as much as possible everywhere. So it’s very simple for single tooth. [Jaz]Now just a question on that, just making it really practical, just basic occlusion checking is, if you put in your article paper and you fold it, so let’s say you’ve got roughly 30 microns and the patient bites together and you want to see it pull through because it’s clearance, but do you then check again with the patient clenching really hard and then you don’t mind if it just contacts a bit? Is that right? [Devang]Yes, clenching hard, I want, I mean, if you really want to assess with the clenching hard, then you want to put shim stock in there. When they’re clenching hard, your shimstock may be just about to, just about whole, but you should be able to still pull through, but you may feel a little bit of resistance when they clench hard. [Jaz]Like a drag, like a shim drag basically. [Devang]Yeah, exactly. That’s what, but if it just pulls through and there’s a little bit, a small gap, I’m not terribly worried about that to be honest. I don’t want too much load on my implant. [Jaz]Here’s an interesting question for you then Devang. If you, let’s say you’re doing a lower first molar implant crown. Okay, and you want it out of the occlusion. Now, let’s say this patient is half a unit class two. Therefore, the opposing tooth would be like an upper molar as well. So, now you’re out of the bite, but over time, wouldn’t that upper molar just keep erupting, keep compensating, keep coming into the bite? Because it doesn’t have like half a cusp on the tooth behind or tooth in front. So how do you guys deal with that? [Devang]Yeah, that’s a really good question. And I don’t have the answer to it, to be honest. What happens is, which I’ll cover in maintenance is that when patient comes in every yearly, you would assess the occlusion. And what I’ve found in many time is that’s exactly what’s happened there. Especially sevens. Sevens are buggers because you create a clearance, and you lose it like this. Like when patient come back, I can guarantee you that you lost that clearance, which you made in a year’s time. There are a few options you have, you’re either adjust the opposing tooth because you definitely, you don’t want your implant to be loaded. Unfortunately, you will, there are lots of problems, lots of issues. I actually saw a patient this Thursday came in with a loose crown, screw retained crown, and that was because I fitted the crown and then I checked the occlusion. It was proud. And that crown’s been there in six years in his mouth. So I know I’ve checked it last year and he wasn’t proud. So it just becomes, it was the first, almost first point of contact and it was last tooth in the arch. So recurrently, this is how I manage. I either adjust the implant crown. or adjust the opposing tooth. Generally, I adjust the implant crown. And that’s it. I leave it like that. Now I’m starting to change my philosophy in the sense that I don’t think the material we are using for implant, I don’t think it’s the right material. I think we should be using more sort of a shock absorbing material, such as like a composite for implants, where we can get away with a little bit of occlusal load, where it absorbs the shock of that little bit of occlusal load. Otherwise the same thing happens. Keep teeth keep moving. We know that teeth move all the time. That’s what I do, for now, but I don’t have any robust answer as to what to do. Then someone would say, okay, give them a mouth guard, give them Essix retainer, so teeth don’t move. Studies have shown that it’s not reliable. Teeth still move, like small movement, it still happens with the Essix Retainer on. But if you want to be a bit more- [Jaz]Yeah, because we’re dealing very minimal amount of microns. [Devang]Yeah, exactly. But you can give Essix Retainer just to make you feel a bit better. I’ve tried both ways and I’ve still seen teeth move. Because exactly, we’re looking at microns, we’re not looking at millimetres. [Jaz]Fine, so you’ve checked the occlusion thoroughly, static and dynamic, what next? Are you finally going to switch, get your screw, the one that you have, the one that you bought, independently? [Devang]Yes, so, what I tend to then do is, once everything’s fine, I’m happy. This crowns fitted. I’ve shown it to patient patients happy. At this time, I show them the screw access hole as well, that there is a hole in the crown. They usually don’t feel surprised because I would’ve shown them during my consultation that this would happen. Initially, I didn’t. And then patient’s like, what you going to gimme hole in my crown? Like this is a new crown and you really get a crown with the hole in it. So I need to, I generally explain it to them on the consultation appointment that this is how I approach it. So I show them everything, explain that our hygiene patient’s happy. Then I would take the old screw out, swap it with the new screw. And I would hand tighten it. And I would put a PTFE in there and then I would put a, some sort of a material like a clip or sort of temporary composite material in there, in the excess hole. Generally, so I put a PTFE until, let’s say, 3mm spaces left. So you don’t need, like, small PTFE and a big TFM sort of a material. You want big PTFE and then small material. It just makes your life easy next time when patient comes in. So I would do that and then I will let patient go for a test ride. So that I’ll see patient for anything between 6 to 8 weeks after I’ve fitted the crown for a second, for a review. To make sure patient’s happy, I look at the gums, make sure everything’s happy, take the photos, because on the day, gum will be blanched, so, you don’t want to take photos on that day because it won’t look nice, so you want to wait till six weeks anyway, six to eight weeks, but mainly patient would give you an opinion. With a screw-retained crown, it’s really good, if patient comes back and like, I don’t like this, I don’t like that, you unscrew it. Put a healing about them back, send it back to lab for whatever amendments you want to make. So it’s fine. However, I tell patient that as we know with porcelain, if you’re using UCLA type crowns, where the lead porcelain, they’ve used a PFM type porcelain. The longer it stays in patient’s mouth, refiring, when you want to change, it becomes a bit trickier because of the water content. So the water goes into the crown, it gets moisture in there, and then when you put it in a furnace, there is a chance that everything just breaks apart. So I tell patients that if you don’t like anything, don’t wait till six weeks, just come sooner, okay? But generally, 99% patients like fine. Everything’s happy. They’re happy. So when they come back in six to eight weeks time, then I would torque the implant. And torque range, it ranges from 20-35 N-cm. You need to check which implant company you’re using, and you need to use a torque setting to the recommended implant company. So Neodent, I know, I think they recommend 20, Straumann’s 35. BioHorizons 30. So it depends really what kind of torque range implant system you’re using. I’ll torque it. [Jaz]And does each implant system have its own torque wrench? Or does one torque wrench be applicable to all the systems? [Devang]No, but just to make your life difficult, each company will have their own torque wrench. However, each company will have a machine fit driver, which means it’s a latch grip driver. Now, if you have a torque your own torque wrench, you can put that let’s grip into your torque wrench and you can use one torque range for everything. But generally your restorative kit would have some sort of a torque wrench which company has provided. So it’s not a big, big issue. When you are like me and you’re treating like multiple implants and everything, then it may be worth having a universal torque wrench kit where it comes with a handle. I don’t know if you remember, when we removed gutta percha for doing post and core preparation. We used to have this handle and then you snap the drill into the handle rather than using the slow hand piece to remove the gutta percha you can use a handle and use the hand to remove the gutta percha. So you’re not really removing it too much. But at least at Eastman we used to taught it like that teach it. So you can use a majority gutta percha with the hand piece and the last bit you can use with the hand. But it’s basically a latch grip. You can just put it in the handle and you can use it. You can torque it and then a new PTFE. If you, let’s say patient comes back and your crown’s loose, the screw is a little bit loose. Then you need to go back and check whether your contact points a bit tight or why this screw became loose. Generally, they don’t become loose that easily. So you need to make sure that it doesn’t, if it has become loose, then I’ll retighten it. And review the patient again, in six to eight weeks time. I don’t want to become loose within eight weeks time, even if I’m hand tightening it. That means there is some other issue going on. So once it’s fine, I’ll torque it. I’ll irrigate the channel, make sure there is nothing in there. Dry it. PTFE, new PTFE. Now, there are lots of material people have used. So not just PTFE, they’ve used antibacterial seal to seal the whole access hole. But I’ve seen studies and they recommend PTFE with composite on top. Works fine. Cotton wool actually doesn’t work very well. So PTFE is much better than a cotton wool. So PTFE again. And then if you have, if your technician has done their job properly, what you would have is you will be able to see the screw, the metal channel extending right just above the occlusal surface. So just one millimeter shy, because you want metal to cover, support the whole porcelain, right? But the problem is with the screw retainer, especially the mandibular, let’s say molar, it doesn’t look nice when you put the cement, the metal shines through. Okay. So patient will be like, it doesn’t look nice. So, what I tend to do is PTFE, 3mm gap, and I have a Opaquer. I use a similar Opaquer where technician would use for composite to hide the metal. So I would use Opaquer to bond to metal. [Jaz]Is this like a liquid form? Like a Tippex kind of thing? [Devang]Yeah, it’s a dental version. Do you know a pink opaquer from Cosmedent? That works fine. [Jaz]Yeah, I use the Ivoclar one, the direct opaque. [Devang]Yeah, same thing. Any opaquer. So I would use silane metal primer first to prime the metal. Dry it. I tend to use bond. There is no evidence behind it, but you can use a little bit bond. Cure it and then metal opaquer. Cure that and then composite and that will mask the hole. You don’t want to mask it very, very nicely because obviously you want to go back again. You might have to go back again at some point. So you want to see where the marginal hole is. So I would explain to patient always and patients generally are fine. They don’t, they’re not that fussy. [Jaz]Yeah. I’ll just ask a timely question then Devang, because you mentioned the fact that you want the retrievability. So you want to be able to go in again. How often, like for restoring the single implant crown let’s say a premolar molar and you see them at the six to eight week control and then this time you’re going to use a torque wrench whereas before when you fitted it you used the hand tightening but this is the first time you use a torque wrench you do your PTFE you do your Clip or Telio or whatever. How often through the lifespan of the next 20 years on average would it be required for someone to go back in and remove the clip, remove the PTFE and unscrew it? Obviously, there’s going to be various reasons this can happen, but is there an average in your experience so that you have to go back in? [Devang]Well, I would say less than five percent. So you don’t have to do too many times, like less than five percent of the patients would need me some inter- and generally there is a reason behind it. Either they chipped something, there is an inflammation or they have some sort of- [Jaz]Screw loosening. [Devang]Have done or something. Yeah, screw loosening. Screw loosening is more prevalent with the implant with the butt joint than the conical connection. So if you have a conical connection, screw loosening is much less unless the occlusion comes in a way. So if occlusion changes, then there is a screw loosening. So these are the reasons. Generally, I would say posterior teeth, you get more through loosening the anterior teeth again because of the occlusion, but yeah, so not very often if patient comes in for a review, so that’s really, as you said, timely question. So the next thing is really a Maintenance. When patient come in for maintenance appointment, right? So now you’ve seen patient, torqued it, filled it. Now I would tell patient that, okay, I’ll see you in a year’s time. So I’ll see patient in a one year time for a review. So when the patient come back for a review, in a year’s time, I would make sure that I’ve done the full assessment, I gain occlusion. First thing I check because that’s the thing support probably would have changed. I would assess the pocketing. Now, there is a controversial thing where there are some people recommend to pocket probe around the implant. Some people don’t recommend probing around the implant. And there are two different camps. I gently probe around the implant because without that you’re kind of blind. But I’m not going to worry too much if my probe goes down as far as there is no bleeding because you need to imagine that the implant is quite subcrestal. Crown and abutment almost will be four millimeter before it emerges out from the gum. So three to four millimeter. So pocketing of three millimeter is not really a pocketing. You’re going towards the implant level really. So, plus it’s very difficult to probe because of the convexity of the crown. So you don’t know. So what all I’m checking is when I do probing, is there bleeding or not. I’m checking that I’m taking a radiograph to assess the bone level to make sure everything’s fine. Checking occlusion, checking mobility of the crown. So make sure you check. literally grab the crown and just try and move it to make sure that it doesn’t move. So these are the main checks I do with regards to implant restoration. Now, if there is a bleeding and everything, we can then discuss next, but it’s very simple, few checks when patient comes back for a review. So it’s nothing really complicated. [Jaz]And at this point, how many years would you continue to see this patient for? For doing that protocol and for how long do you take PAs for? Is it every year for five years or any guidelines on that? [Devang]Yeah, so generally the protocol which I’ve read in old ADI website, I think it’s still valid, is that you need to do it for two consecutive years. And if you don’t see any changes in the bone, everything’s fine. Then you can do it every other year, every three years or something like that. So you don’t need to take it every yearly radiograph. I give after two years. So I would do it for two years. After second year, everything seems fine. Then I give patient an option. I tell them that, okay, you have an option. You can either see me every two years or you can either see me still every yearly. I personally prefer to see patient yearly. Like, nice guidelines about patient. Some of the patient. You can-do two-yearly checkup, right? If there is a very low risk of caries, just generally, generally. Yeah, I just don’t agree with that personally, because there’s so many things can change in two years. People, lifestyles can change. Their habits can change. So, you don’t know what you see. In two years time, things can be completely different. So I prefer to see patient on a yearly basis. And I tell them that, look, you’re paying me whatever review, assessment appointment for like five minutes for me to have a look in your mouth. But I would rather you do that. Then I have to work hard in your mouth because you cause some problem. But it’s entirely up to you. If you want me to see you, I would prefer to see you. But if you say, look Dev, I want to save money and let my general dentist assess my implant, then that’s fine. So I give them an option after two years. First two years is kind of non negotiable. So I tell them and they’re generally happy with that. And then after two years, some patients would be like, look Dev, there’s nothing wrong with it. I don’t even know which tooth is implant. And also if the patient is our own patient, then I feel a bit more comfortable because all our associates understand how to assess implant. So I’m comfortable referring them back to their dentist. And I know that if there is any issue, the dentist will refer a patient back to me. [Jaz]Amazing. So that’s the maintenance capped up there. And then troubleshooting. I mean, one thing that I wanted to ask you by saved it for troubleshooting is a scenario whereby you’re placing the crown back from the lab and you’re getting maybe excessive blanching, or the soft tissue is just, it’s impeding the seating of your crown too much. At which point do you get out the laser or do you get out some sort of a gingival removal? Is that something that you want to cover? [Devang]Yeah. Okay. So it generally doesn’t happen. The reason being that if I feel that I want a bigger emergence profile, I would have put a bigger, wider healing abutment to already while when I do the second stage surgery for me to get the the structure of the gum ready for my final crown. I sometimes do custom abutment if I feel that I want a better emergence profile. So I would have done all that before I fit the crown in. So it would have been done before. It used to happen when I started restoring implant where I would use your wrong healing abutment, like a very small one, because like if you use a big healing abutment during the second stage. You need to know how to close the wound if because it’s difficult to close it before the big healing abutment. So I used to use a small healing abutment so I can close the area nicely. And then when it comes to doing fitting of the crown, crown would always be like really really stretching the gum. So no laser, nothing. I would give patient obviously LA by this time patient would have been pain anyway. So you need to give patient LA, use a blade to just put into proximal incisions to sort of a crestal incisions, loosen the flap a little bit and put the crown in. So what will happen is the ground gum has become loosened. You literally move the gum, crown goes in. If you feel that it’s opened up the flap, then just a couple of interdental stitches and then that’s it. If it’s not, then you don’t even many time need to use the stitch. It will have a small gap interproximately which will heal by secondary intention. Okay? Does that make sense? [Jaz]Okay, very good. What other complications do you want the general dentist to know about? [Devang]Okay, so there are 6 plus 1 because you discussed last time about the open contact points. So we’ll cover that. So let’s start with that. So, apart from high occlusion point, which you must check because you will see much more commonly than normal. And this is when you would understand that occlusion is very dynamic. It keeps changing. So, this is when you realize because implant doesn’t move. And then if you know, you’ve made sure you got 30 micron clearance and patient comes back in a year’s time with a high occlusion on that tooth, you know that something’s changed. That’s the main thing that’s the most commonly happens. So I would expect that on my review appointment. The other thing can happen is open contact points. Now there have been studies done and we know that the teeth have the tendency to move mesially. So there is a higher probability with the molars. There is lower probability with the premolars and the higher with the molars because of the bite and everything that there will be mesial open contact point at some point in next 10 years. Okay. The studies done for five years and the probability was probably, I think it was 38% to 42% that there will be some sort of an open or light contact will develop. However, the good thing is they could not find any correlation between open contact and peri implantitis. So, they didn’t find any correlation between open contact and any issue with the implant itself. So that’s a good thing, but obviously, nonetheless, that can happen. The other scenario can happen where there is a space distal to the implant. So if I placed restored 6, there is open contact between 6 and 7. There is no clear cut answer to that. There is no study suggesting, oh, if this happens, you do this. What’s clear is that the occlusal splints doesn’t work. So if you give patient Essix Retainer, it does not work. But you by all means give them just for your security. So what are the other options? Someone has suggested that if there is a space between 6 and 7, you could do occlusal adjustment so that 7 is not as high, not too much load on the 7, because the theory was that because of the occlusion, because of the closure backwards, causing the space in the front. So you can, if you need to see if there’s a first point of contact on that seven and that’s causing the space. What I have done in past is I’ve done two things. One is if it’s a light contact, then I don’t do anything. Just leave it and monitor it. If it’s open contact, then I have done in past, taken the crown off and send it back to lab to add some material on there, which is a lot of faff. What I’ve done in past is this is a normal tooth on either side. Then I would add composite to the interproximal surface of the tooth. So to close the contact, basically you take the can off, add some composite to close really. [Jaz]That’s what I’ve done before actually. Like if there’s a DO composite and then you just make the DO wider. [Devang]But none of the study mentions that, you know. So then you’re thinking, am I doing the right thing? But that’s the logical thing to do, really. There is no clear-cut answer, if that makes sense. So does that answer your question? [Jaz]Fair enough. What are the other three? [Devang]So the number one scenario, which is not really a complication, but it’s a scenario where patients come to you, and patients, because they love you so much, they want you to restore their implant. So someone else has placed the implant or someone has already restored the tooth, but the tooth is fractured, porcelain is chipped or whatever. And now patient wants you to restore that implant. What kind of information would you need? So first of all, when patient like that comes in, I might always, even though I can restore implants, might always go to suggestion for patient is to go back to the dentist who’s placed the implant. Not because I don’t want to take responsibility. Especially whether it’s in UK because it will be cheaper for patient to get it replaced by the dentist who is referred. So now if I have done the crown if patient comes back to me within like less than 10 years time and needs a new crown because I’ve done it. I have all the instruments. I have all the healing abutment. I have impression post. I won’t have to source it If that makes sense. So my life is easy. So I generally don’t charge patient much more than a normal crown fees. But if patients coming to me and with the implant, which I don’t restore generally, I would add probably four or 500 pounds more. Because I need to source all the material. I need to call the rep. I need to get the impression post. I need to get the drivers. [Jaz]Devang, I think that’s totally fair. Like, it’s kind of like an inconvenience fee, right? Because you’re seeing someone. It’s like the patient may know you and love you, but it’s the tooth. The implant is still a stranger to you. So I think that’s completely justified. I think you had two more complications you wanted to cover. And I’m going to then go back to complication number one. I just want some more information about that. But let’s just finish off the two complications. [Devang]Okay. So, so this one actually, so I just took, close this conversation, this first one, the patient’s coming, you need to know few details before you can restore the implant, right? So you need to make sure that you know when the implant was done. What, when was it done? So if it’s like 15 years ago, you may have an old implant. You need to know, you need to do clinical assessment to see is it viable for patients to spend another 1500 pounds to restore the tooth with implant crown. You need to take periapical radiograph. And I take a small CBCT to really check the implant, because I don’t want to charge patient 1500, load that implant and then realize the implant fails because there is no bone. [Jaz]Do you not get like lots of scatter from the implant? Is it possible to get this data? [Devang]Yes, you can remove scatter from implant sort of smart CBCT assessment softwares can remove, scatter enough for you to know roughly. Now, if there is a one millimeter bone buccally, you will not be able to see it, but generally you will get an idea, vertical height of the bone. You’ll get some idea of the bone.And then you need to make sure you know what type of implant it is. If unless you know what type of implant is it? You can’t restore it. And then, as I said, you need to consider the fees. [Jaz]Do you use that website Devang? What’s that implant dot com or whatever? [Devang]Yeah, I know it was helpful to me. Like there’s so many, so many implants in there. You get locked down. [Jaz]They all look the bloody same. [Devang]Same. Yeah, they all look the same. So what I do is I go by when was the implant done. If it’s pre-2005, then it is more likely possibly Nobel or Straumann, some sort of a older companies. And I ask around most of the time, someone from the group somewhere would know what implant it is. [Jaz]I think there must be some AI now that there must be some AI where you upload your radiograph and the AI will tell you which implant that is, rather than, I know that’s the whole point, the website, but then he still gives you some options, but now it just does all the work for you. It actually tells you, is this implant? [Devang]Yeah, that would be amazing. So the second most common complication you would come across when you are doing screw retain restoration is the screw hole comes out from the buccal aspect. Okay, so if the implant is not in the right position placed not in the right position and you want to make the screw retain crown, but the screw access hole is coming out buccally then if you’re restoring central incisor, you can’t really restore the incisor with the aesthetics. So then you need to do an angle correction. So in angle correction is all it is, is basically a screw head and a special screwdriver where that screw driver can engage that screw head at a certain angle. So you can tighten, you know, usually to tighten the screw, you need to go 90 like straight to the angle of the screw head and then you tighten the screw. Now, if you want to tighten the screw with the 25 degree angle. You need a special screw head and special screwdriver so you can avoid the angle. You can still tighten the screw because the fact that the screw needs to go into the implant doesn’t change. Implant doesn’t change where it is. So now you need to, you’re thinking about the excess of the screw hole and if you have a special screwdriver, then you can, and that’s all is angle correction basically. So you’re not angle correcting implant, you’re angle correcting, not even a screw, you angle correcting your screwdriver so that your screwdriver can fit into the screw at 25 degree angle. Does that make sense? [Jaz]It makes sense to me but this is all so that we can still do it in screw retain and avoid the cement retained. [Devang]Cement retained, exactly. Now the other option is you can go straight to cement retain, avoid all that issue and cement retain crown. But now 25 degree screw channel angulation correction is very common nowadays and very predictably done, so I wouldn’t hesitate doing the angle correction. Now- [Jaz]And this is all, like, all the hard work here is pretty much done by the lab, right? You’re just writing on your prescription and they just send you it, so really- [Devang]You’re not even writing it. [Jaz]Your steps aren’t, yeah, okay, the lab will know, yeah. [Devang]Yeah, you’re just telling them, I want screw-retained crown, so the lab should call you saying that, look, the crown needs angle correction. Most of them, the problem is that the lab doesn’t call you. They will just use angle correction screw and send it back. And now you’re thinking, oh, my screwdriver doesn’t fit into the crown because you’re using normal screwdriver. Lab hasn’t told you that they’ve used an angled screw and you need an angled screwdriver. I had a dentist who fitted the crown. What happens is the screwdriver, normal screwdriver, went into the screw and half turned the screw in. Now the dentist couldn’t turn it back off and couldn’t tighten it either. So the patient came with a dangling crown to see me. Just because I had this, so, lab communication is really important. So lab must tell you what screw they’ve used so you can use appropriate screwdriver. But you’ll be surprised how many times labs don’t tell you, give you the information. [Jaz]And this is like all part of the kit, like, whichever implant system you use, you got like different degrees of angles of screwdrivers. Is that right? Is that how it works? [Devang]No. So again, no, it’s a separate kit. So you need to buy a separately that screwdriver depending on what screw channel. So the lab would have tell you that they’re all same, angle corrective screwdrivers, you can use one angle corrected screwdriver for everything. It’s not true in my book I’ve got several screwdrivers lined up and you can tell that they are different heads. So you need to know- [Jaz]Is there a 15 degree one different to a 20 degree one different to a 25 degree one? [Devang]Yes. But in similarly like if you have a 25 degree one, you can use it for 15 degree correction. Does that make sense? It’s not like that. So but Straumann has their own angle correction screwdriver, the Createch lab, which mills the thing in Spain, they have their own angle corrected driver, Bio Horizon they have their own, Nobel has their own. So it’s a plethora of angle corrected screwdrivers. Now if you can’t angle correct because it’s more than 25 and you still want to do screw retain crown, then what I have done in past once is when patient came to see me where her bridge was de cementing. Someone else placed the implant, cemented implant bridge, de cementing. So we wanted to make a screw retained bridge and the screw hole were coming out buccally. So we made a composite bridge. So metal framework with the composite on top with the buccal screw holes. I tightened the screws and did a buccal filling, buccal veneer on the thing. So masking the screw hole. Okay, so it’s a composite bridge. And that’s the compromise again. Where you cannot really even angle correct. [Jaz]Okay. And it is a composite bridge because you were able to then use your direct composite to fix it. [Devang]Yes. To fill the hole. So that’s the really, the main complication if you want to make a screwin crown would come across. Now the long term would be really generally two things. Screw loosening we already discussed. But when you, when patient comes with a screw loosening, you need to make sure you take the crown off. Don’t just tighten the screw because food and back, everything would have gone under the crown. So take the crown off, clean it with the brush, disinfect it with the chlorhexidine, clean the area of the gum, everything in the implant, and then fix the crown back in again. Don’t just, like, screw the crown in. Okay, because you are then pushing all the bacteria back into the screw channel. So you need to disinfect, dismantle everything, clean it and put it back in. [Jaz]And then thoroughly check the occlusion again. [Devang]Yes, 100 percent. Yeah, 100 percent. And there will be some issue with occlusion unless there was issue with the contact points. And then obviously there is a bleeding. So if you feel that there is a bleeding around the crown. Give it a good clean using either titanium instrument or the plastic instrument, which I find plastic instrument a bit of rubbish. They don’t do anything. So you can’t use ultrasonic around implant because it just scratches the implant surface and the crown. So you need to use titanium instrument or they are like a jet wash sort of a perio jet instruments around. So you can use that to clean around it to break the biofill, but it still doesn’t work. Give patient oral hygiene instruction If it still doesn’t work Then you take the crown out, scrooge and crown, put the healing abutment back in again and let that heal because sometime I would notice that patient hasn’t been good and they start, there is inflammation. And the cycle starts because there is an implant crown, patient can’t clean properly, patient can’t clean properly, there is inflammation. So you need to break that cycle by just taking the crown off and giving the healing abutment. That leads to another important thing, that when you finish treatment, give patient everything back. Which means you give patient, most of the components, the implant companies are clever, they are 2-cross. So in the sense you can’t reuse it anyway. So you can’t reuse healing abutment, you can’t reuse impression post. So I give everything back to patient. I can’t store everything everywhere anyway. So I give everything back to patient, including their provisionals, which I give if they needed one, which I give them back and get them signed that paperwork that they’ve got it. So if I need to remove the crown back, I use the same provisional which I fitted before. So if I’ve given them denture, I fit the denture back in because they need some, if it’s an anterior tooth, they need some sort of a provisional, right? So they don’t have to pay again to make the new provisional. [Jaz]And at what point is this implant passport that I’ve heard about? Giving patients so they have this information carry around? Is this something that you do? Is it something that’s company specific? How does this work? [Devang]I don’t do implant passport. So I do like every company does it. But what I tend to do is I do this where at the end of in a discharge patient, when let’s say, the eight weeks appointment review appointment, I’ve talked everything at that discharge appointment, I give them a clinical log sheet. So I have a log sheet with the stickers of the implant and components and everything. So it’s a A4 size paper with the table on it. And I scan that and give them that. And I give them the consent form saying that I’ve hand over all the lab work material and what I have given it to them. Everything’s in there, patient sign it and take it. So that’s all with the patient. So patient knows, but most of the patient, they end up losing the information and calling the practice if it’s needed. But at least you’ve given them the information. So I think these are the really the main complications which you need to be aware of. [Jaz]Well, the only one I had a question about then is, again, about frequency of things, right? As someone who doesn’t routinely restore implants, I’d like to get an idea of how frequent it really helps when you give me a 5% of the time, 10% of the time. So this thing about constantly, dynamically checking the occlusion to make sure that things are no longer proud where they weren’t before because things are always changing. How often do you think there will be some adjustments being made? For example, you see a patient annually for the next 20 years. Is it that every patient for every 20 years you’ll need to do a little tickle or certain percent of patients for certain years? Any guidelines on your experiences? [Devang]So my experience is that some patients are more prone to the others. So I have one patient every time I see. Occlusion is a little bit high every time I see, but majority of the time, let’s say you will have 70% of the patient, nothing would have changed. Let’s say in five years, maybe one time adjustment, maybe. [Jaz]Okay. [Devang] I haven’t been placing implant for 20 years, so I can’t really, I’ve been placing for 13 years. So I can tell you 13 years experience. So it’s probably five years, I would say yes, but there will be 20% to 30%, which is still a high number of cases where you will have to adjust it. Maybe every other year, if you, or every three years. [Jaz]That does help. It just highlights the importance of it and highlights the frequency of it. And I think in terms of a common complication, which if it goes undetected, can lead to more porcelain chipping, screw loosening, and maybe even overload and failure. Dev, you’ve covered a lot in these two episodes, as I always like to ask my guests, where can we learn more?I know you, you mentioned the book a few times, your occlusion, your FMR book was a huge success. Tell us about the implant book and where else we can learn from you. [Devang]So the implant, yes, I’ve just finished writing an implant book and this time the implant book is part of my full core course. So the way I’ve structured this is I have an online course implant book and a hands on course. It’s a full circle where if someone comes into that, they will end up restoring implant by the time they leave and finish the course. So if they need more information, then I’m available on social media or they can contact me at info at drdevangpatel.com. [Jaz]Any website yet? [Devang]So I, yeah, I have a drdevangpatel.com website. So it’s www.drdevangpatel.com. That’s the website. [Jaz]I’ll put it in the show notes. So you can just click on it and the implant restorative course is on there? [Devang]Yes. So it’s coming soon of course. So it will be launched by end of August. [Jaz]If you guys don’t know Devang, like he’s such a brilliant educator. He gives all his delegates so much of himself and his energy. Like he, as you know, already, he gives all of his patients his mobile number, right? You said that, right? And I’m pretty sure you give all the dentists your mobile number as well. So you must be like the busiest guy ever which I know you are. But you will always go out of your way to help a dentist. So if you’re always looking for people to learn from, Devang is very, very good person to, as a mentor in any realm, where there’s FMR implants. So, I appreciate everything you’ve done in terms of giving to the Protruserati, all this knowledge and for some of them who need handholding. I was strongly encouraged to look at Devang and it’s a big topic. Where do I learn restoring implants from? So, I’m hoping they’ll be able to learn those things from you because you’re so good at supporting them. You see? [Devang]Yeah, I hope this two episode would help them as well, because as I said, my aim is to give everything and then some people would just say the episodes enough and that’s fine. I don’t generally hide anything. So, it’s not like you come to my course, I’ll give you more. It’s everyone should be, you get information in all sorts of formats. [Jaz]It’s like case specific, right? [Devang]Exactly. [Jaz]Case specific. And there’s so many nuances to every single individual case that can’t be covered in an episode. And that’s where if you’re taking this seriously, but you need a course or a mentor, that’s where you come into equation. So I’ll put all the links below. Dev, thanks so much once again for really wowing us. You did the whole FMR series many episodes ago, and now they’re storing implants. I don’t know how you find the time to write these books and do these things.It’s quite spectacular. So, kudos, my friend, but keep going, my friend, keep going, because what you’re doing, the energy you’re putting out to the world, it really helps all dentists. [Devang]Thanks for having me, Jaz. And thank you. I’ve learned a lot from the community itself as well. So thank you again for giving me the opportunity. Jaz’s Outro:Thank you. Well, there we have it, guys. Thank you so much for making it all the way to the end. Remember, you can download a guide or a summary and aid memoir of the previous two episodes by going to protrusive.co.uk/idiot. Now, if you’re someone who hasn’t reviewed the podcast before, would you consider reviewing it today? I’d really appreciate that. So whether it’s on Spotify or Apple or wherever you get your podcast, consider leaving a review if you learn something with me and Dr. Devangkumar Patel. And again, thank you to Devang for being a brilliant guest, not only in this series, but also the Full Mouth Rehab in 11 appointments. If you haven’t heard that series before in the podcast, do check that one out as well. If you’re part of Protrusive Premium, you can answer a few questions and get the CPD, like you’ve already listened to it. Just verify your learning, do the reflections, and you’ll get your CPD or CE certificate. And that of course you can access on the web on protrusive. app, that’s protrusive.app, or on your app, whatever you prefer. I’ll catch you guys in the next episode of Protrusive.

One of the reasons I did not proceed further in Implant training is the sheer frustration and confusion surrounding all the components and nuances of restoring Implants. This is why I have Dr. Devang Patel sharing his 13 years of experience in the field to break every stage of restoring a single implant crown. All the terms, components and stages for implant restoration are explained during this 2 part series. https://youtu.be/TAzbZW_Yk_Y Watch PDP156 on Youtube The Protrusive Dental Pearl: How I use the software Motion to better manage my time and productivity. Check out the 7-Day Free Trial Here Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode:00:00 Intro01:56 How I use the Motion App04:26 Where to start?07:03 Dr. Devang Patel13:30 Assessment and treatment planning22:19 Space requirements27:49 Temporaries28:48 Occlusion and diagnostic wax-ups30:10 Impression technique39:31 After the impression42:29 Connections48:19 Screw-retained crowns vs. cement-retained crowns58:18 The lab67:39 Digital impressions72:15 The next episode74:48 Outro If you liked this episode, check out Adhesive Full Mouth Rehabs in 11 Appointments (Part 1) – PDP103 Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month? Click below for full episode transcript: Jaz's Introduction: If you're like me and you don't restore implants and you want to learn more about this area or if you're new in the game and you've got your first couple of cases on the go, this episode will be absolutely invaluable. If you remember Devang, he did a few episodes with us about full mouth reconstruction in 11 appointments and he went through appointment by appointment, and that episode is like a Protrusive Hall of Fame. Jaz’s Introduction:In that same style Devang covers over the crosses two next episodes, the Five Different Stages of Restoring the Single Implant Crown. We’re going right to the basics, starting from assessment all the way to screwing or cementing your implant crown, and we leave no stone unturned. Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. For me, implants are super confusing. When I was in the first few years after qualifying, I did go on some courses to learn about restoring implants, even learning about placing implants. But I just decided it wasn’t my bag. It’s not what excites me. Orthorestorative excites me, occlusion excites me, and implants are at the moment in my career is not something that I’m spending more energy and time on. I’m doing a lot more TMD now I’m doing restorative but who knows what’s in store for my future. But as we know dentistry is a long game and that could change in the future, but I definitely needed to serve my patients better by learning more about implants in general. I think we can all do with foundational knowledge and where better to start than learning about restoring implants which is exactly what Dr Devangkumar Patel will do today. Now, please, no one be offended by the episode title, An Idiot’s Guide. If you listen to the end of the episode where we discussed naming of this episode, it’s a bit funny actually, but I mean this with the best intentions because actually when you listen to the interview, you’ll see that I’m stopping Devang and I’m like, hang on a minute. When you say this, do you mean this? And I’m learning as we’re going along. And when we’re talking about internal hex and external hex, for me, that just got really confusing. So I made this analogy of like a belly button, like sticky-innie, sticky-outie. So, you’ll see lots of Jazz-isms in there about me just trying to break things down, trying to make it tangible. So please, no one be offended by the title. Protrusive Dental PearlThe Protrusive Dental Pearl today is from the recent webinar I did. I did All My Productivity Secrets Revealed. Because you guys ask me all the time, like, Jaz, how do you manage to be a father, work in clinic, have a podcast, do all these courses, social media, et cetera, et cetera? So, I gave away every one of my 17 secrets from getting someone else to do your emails and getting a PA to getting a team for social media, to little things that which apps to use. So, I’ve covered that all on this webinar and it’s now available as a webinar replay. So, if you head to protrusive.app as the website, that’s protrusive.app and you make your login, you can access that right away. There’s even a two-week free trial you can use. One of the secrets I shared is how I move from a to do list to a calendar. Because the problem with to do lists is that you make this very ambitious list, right? We often overestimate what we can do in a day, and we underestimate what we can do in a year. So, our daily lists are just way too long. And then at the end of the day, you feel really down that you didn’t even cross off half the things on your list. Instead, I now put it in the diary. So, I know that this task will be done at 2PM to 3PM on this day, for example. By slotting it into a diary space, you know it gets done if you respect your diary. The problem is life happens and you don’t always get to do the things in your diary, right? So again, I used to hate having to move things and edit and move it to like a week afterwards and try and think where I can slot this task in. Now I use something called Motion. So, Motion is like a calendar app, and it’s like a, it’s a replacement for Calendly as well. It’s a replacement for Acuity Scheduling, which I used to use. So, you can actually book meetings, ClinCheck reviews with patients. You can book meetings with others who sort of book into your diary. So it’s a really good calendar tool in general. But what I love about Motion and the reason it’s called Motion is because let’s say you set some tasks in your diary; you diarize it. If you don’t complete it that day, it then figures out where in your diary it should place it in the future based on some parameters that you set, like how high of a priority that specific task is, which days you’re willing to work on these kinds of tasks. So Motion actually decides using AI technology to where it should move your task into the future. So I love this. It’s been great for me. It’s pretty cheap. It’s about 170 pounds, $228 a year. So if you’d like to check out a free trial of motion, head to protrusive.co.uk/motion. That’s protrusive.co.uk/motion and just make sure it’s right for you like using it. I did a seven day free trial first and it worked well for me. So I ended up taking it and by taking a membership, I was able to cancel my Acuity membership basically cause I was already paying for that for booking meetings and booking links and stuff. This does all that. It is like Calendly and Acuity, but much more with the whole AI integration and your diary. I have to say I wasn’t that overwhelmed by the mobile app. So I use it on the desktop and I like how it syncs to my Apple calendar or whatnot. I try it for free. And then if you like it, then obviously go with it. If not, then at least you tried something. It’s got to work with you and your workflow, but I’ve warned you. The mobile app is perhaps needs to a bit of work on it. But the desktop app is what I use. And that works really well. This is an affiliate link by the way. So protrusive.co.uk/motion does take you to an affiliate link. So if you do sign up, we do get a small commission, which goes towards supporting this channel. If you want to catch all the other 16 secrets, then do check out my webinar on the Premium Clinical video section of the app. Now let’s join Devang to make implant restorations tangible. Main Episode:Dr Devang Patel Kumar, welcome back to the Protrusive Dental Podcast. You are a very welcome guest. Like I said before, if you haven’t heard of Devang’s series on Full Mouth Rehabilitation in 11 appointments, there’s a three part episode. People message me Devang saying that they learned more from that three part episode compared to big occlusion camps that they’ve been to. Can you believe that? [Devang]Wow, I’m humbled. [Jaz]It’s always great to have you. [Devang]You are very good at taking information out, Jaz. So, I think the credit to you as a host. [Jaz]Dude, I’m going to suck so much information out of you today about implants. But, let’s really make it basic. Talk to me like I’m five years old and I’m going to be placing my restoring, restoring. Talking about placing, we’re talking about restoring our first implant. Let’s say, and I’ve heard this before, Devang, is a really good place to start for a GDP is like a lower premolar or an upper premolar. There’s no mental nerve. And so an upper premolar is a great place to start. Would you agree with that? [Devang]Yeah. I mean, for restoration, it doesn’t really matter. Any posterior teeth is fine because we’re not worried about the nerves or any anatomical area because when you receive a case for restoration, you would have hopefully healing abutment in place, which you will go through anyway. So any posterior teeth is generally ideal case when you start doing first. And if you are restoring, maybe you want to look at the CGDent guidelines on implant placement, actually, but it gives you some ideas to how or what type of things you need. Implant is, I always tell people, because I mentor, I used to, well, it’s hard work mentoring for implant surgeries, yeah? So, but I mentor for some of my friends and I always tell them that, it’s all well and good for you to learn, but you need to be able to show here, at least in UK, because of the regulatory body. If something happens, you need to be able to show that you are capable of doing that. So it’s a very good document to go through where you need to really ideally have log, you need to have mentored cases. Because implant is completely different branch kind of as you’re learning dentistry all over again. [Jaz]I mean, this is the same also if you’re doing Botox, it’s the same if you’re doing sedation, if anything that you do that is pretty much a postgraduate discipline, it’s a really good thing to have a log, a reflective log and evidence to show our governing bodies that, hey, you know what? I’m doing the right steps to make sure I am well trained. Now, before we go through the Five Step Process plus the bonus of troubleshooting. So, five steps from going to, Hey, there’s an edentulous region here to actually fitting your implant crown and checking the occlusion and then any troubleshooting. So that’s the way we’re going to go across this two part episode. But before we go in, Devang, for some people who’ve been sleeping under a rock for the last year or so, and they haven’t seen the amazing things that you’re doing, just give us the, a quick one on you and your mission statement, my friend. [Devang]Okay. So I’m Dr. Devang Patel and I am the FMR guy. So I teach full month reconstruction to the dentist and I’ve created formula. I’ve written a bestseller book on full month reconstruction. It’s available on Amazon. I have a Facebook group called Full Mouth Reconstruction for GDPs and I run all sorts of courses. I have a podcast as well, inspired from Jaz, called The Ultimate Dentist Podcast, listen to that. And I talk about full mouth reconstruction on that podcast. And my mission statement is really, I want every dentist, every general dentist practitioner to do simple full mouth reconstruction, and then take up from there because I see now cases on referral basis and I don’t see cases until general practitioners has identified. And many times when you don’t do stuff you don’t even identify because you don’t you’re not even thinking and that’s why many people who do Invisalign they do more Invisalign because they are looking actively for ortho cases whereas if someone who doesn’t do Invisalign, they don’t do ortho treatment because they’re not looking for it. It’s just passing through under their noses and ultimately the patient will benefit. And I always tell them, you don’t need to do MSC diploma certificate courses in order to learn full mouth reconstruction. You need a structured course and you need a structured training path in order to learn. So that’s my admission statement full mouth reconstruction. And you may be wondering, why am I talking about implant today? Right? I’ve been placing implant for 13 years. I’ve placed over a thousand and restored over a thousand implants and I have a passion about it. Most of the cases I receive nowadays are implant related and then I convert them into full mouth reconstruction because many of them need a full mouth reconstruction. But I’ve written a book now on implant and I’ve created an online course and I’m teaching implant because when I teach full mouth reconstruction. Many cases involve edentulous spaces and those that patient who wants full mouth reconstruction, they have a money power to go for implant most of the time. And that’s why many of my course delegates asking me, oh, can you teach us implant? Because they like the way I teach. So they want me to teach them. And that’s why I created this cohort. That’s why I’m asking you to see if I can help anyone else really. [Jaz]Amazing. Now, you made some good points earlier that if you are trained in GDP orthodontics, then your antennas will be more receptive of crowding, base simple crowding that you can help your patients. Now, let me draw a real world comparison, very relevant to our conversation today, Devang, which is if you are implant trained, then you see the dentures area and you think, hmm, can I get an implant in there? If you are not implant trained, you’re thinking denture and bridge as your default. You just are. It’s just it’s the real. It’s the truth. I know the truth hurts and some people like, oh, give a patient all the options. But it’s true. Some implant dentists are probably doing implants where really a resin bonded bridge could have been done specifically, especially for lower anterior, single lower anteriors. Why are we placing implants? That’s my feeling, Devang. You place implants. I don’t, but that’s my strong feeling. Whereas those dentists who are really doing elaborate bridges on like post crowned abutments. You need to be doing an implant, right? Or need to be referring for an implant. So I think there’s a middle ground somewhere. Nowadays, implants have become a postgraduate discipline. Okay, it is what it is. You do some training. Where do you think it starts? Do you think that we should start by restoring implants first, placing implants first, or should we be looking at doing both simultaneously? [Devang]I’ll tell you my journey. At least I started restoring implant at when I did my MSc in Cons. So we were not allowed to place implant until we restored some implants, because the philosophy was that you when you’re restoring it’s failsafe. So, you know, it’s not as difficult as placing and also you will see what mistakes you’ve done the same philosophy where you make your own crowns and you see oh i’ve done under reduction. Does that make sense? Like if you start doing your own laboratory work, you start noticing your mistakes and then when you start doing crown prep you understand, okay, I need to do this. So that was the same philosophy that I was trained. So I certainly started restoring implants and what says for something I would recommend everyone and then see whether that’s your cup of tea, because I’ve known a lot of dentists who invested thousands of pounds learning implant placement, and they’re not placing them because they don’t like it. So I think it’s a safe start to start restoring implant. And then for sure, placing simple implant for a good restorative dentist is it’s really, really straightforward. So I would always recommend to start placing implant at some point, but start with restoring. [Jaz]Restorative consultant, Ken Hemmings, he told me once that taking an impression for an implant crown, obviously we’re talking about scans today as well, but taking an impression for an implant crown is easier than taking an impression for an actual crown preparation. Would you agree with that? [Devang]Ken was one of the person who taught me. So yes, I would 100% agree with that. So it is, if you know the principle, if you know what you want, if you have planned everything right, then I can now place an implant and restore it in totality of on the appointment within 40 minutes. It takes me 15 minutes to place implant. A patient can be in and out within half an hour and then scanning will take another 5-10 minutes and then fitting will take another 5-10 minutes if everything works fine. And I can’t imagine me doing endo. Or even a crown prep. It takes me more than an hour to do a crown prep on a single molar. So yes, it is simpler, but if you make mistake, the effects can be much more catastrophic as well. So it goes either way. And that’s why you really need to know what you’re doing. [Jaz]In my first five years, when I started to kiss a lot of frogs before you find your prince charming. And I was kissing lots of frogs, seeing which is the area of dentistry that I like the most. I went on some implant courses. I went on some restoring courses and stuff. And whilst I, this message was received by me that, okay maybe I can restore implants. Maybe impressions are easier on implants, which obviously going to break down today. Just a sheer number of like connections. You have to talk about screw retain, cement retain, just a different combination. And then to complicate it, different brands of implants, different screwdrivers. I know there’s a proper term for it. It just gets very, very confusing, and overwhelming, but anything worth doing. It has a steep learning curve. There’s not a low entry point. You have to do your hard work. You have to do your due diligence. But a lot of people tell me that once you get there, once you’ve restored a few and become second nature, it can be very efficient, very profitable, and what a great service to your patients. Right? So let’s start my friend. Step number one is identifying. Oh, you tell me what step number one, because you’ve got it all laid out. [Devang]Okay. Yeah. So, the way I look at for any process, I look at it in steps. So again, if you follow me or follow through with my reconstruction, I look at things in steps. So the steps are broken down into five steps. So first step is your Assessment, really, and Treatment Planning step. The second step is Impressions. Third step is Communicating with the Lab because that’s really, really important. Fourth step is Fitting of the Crown. Fifth step is Maintenance. And then, obviously, you have Troubleshooting and complications and how to manage those complications. So, these are the six main steps. And with regards to, let’s start with the step one where we do the Assessment. Before we do this, we need to understand that there is a difference between implant and a tooth. Okay, so the main difference is the implants fused into the bone and tooth has periodontal ligament and that gives you much more proper reception and because tooth has a periodontal ligament and implant is fused in the bone, the mobility of the tooth is different than implant. So we know that if you if you push the tooth down it can intrude up to 25 to 100 microns whereas if you are applying jiggling forces again it can move up to maybe let’s say 56 to 108 micron whereas the implant is fused almost, it has a little bit movement because of the osseous, so the bone moves as well but in less than 10 micron and that’s one of the main reason we will come back to when we are going to discuss about occlusion in implant because you need to understand that the implants don’t move but the teeth do move, even healthy teeth and that’s how you need to manage it. So having said that, let’s look at the time where patient sitting in your chair and now you’re thinking, shall I take this patient for restoration or not? Remember as a General Dental Practitioner, you are the person who’s going to see that patient first before your implant surgeon sees it, okay? So many of the decision need to be made by you and that’s why you need to understand the process of Implant Planning, Placement as well, even though you’re not placing it. And yes Implant surgeon might come back and do a consultation with you and decide, okay, whatever you plan is rubbish, but that’s fine. You learn from planning. Okay. And that’s how I plan. I mean, what you don’t know, you don’t know until you start doing something, right? For any case, my first thing I’m going to check is patient expectation. Whether, am I going to be able to match or my implant surgeon is going to be able to match the patient expectation? It could be realistic, but you’re not trained for it. It could be unrealistic or simply put you don’t like that patient or that you can’t get on with the patient. And that’s the biggest factor for me. If I don’t get on with the patient, I don’t treat them for their sakes really. [Jaz]And with implants, it’s like something that hopefully it’ll be a long term thing. And it’s kind of like orthodontics is that it becomes like a marriage, right? I know plenty of patients who like to go back to their orthodontist or the dentist who did the orthodontics to go back for their retainers and reviews and plenty of patients who, although we can maintain their implant for them now, they still prefer to go back to their implant dentist once a year, once every two years to do that. So do you really want to see his patient in the longterm? And if you’re not going to see eye to eye, then you’re totally right. Agreed. [Devang]Yeah. And with regards to long term as well, I tell all my patient from the day that implant won’t last for a lifetime. And that just breaks the ice and you then don’t have to tell them that there’s 80% chance, 85% success rate over or survival rate over 10 years. And no patient has said no to me because of that, but you need to put it out for upfront and you need to tell them that they don’t last lifetime. Because many times-, I had a doc-, and I learned because I had a doctor, a GP. Once I finished my implant, this was early days. He’s like, oh, now this is, I’m set for rest of my life. And I’m thinking you’re a GP, like, I mean, how many times we’ve done things and you know that it doesn’t last lifetime, not even teeth. Like you buy a hundred grand car. They don’t give you lifetime got a guarantee. So, but that’s something, a mentality really, we need to shift. So once that’s done, then as you really importantly said, we need to really discuss different treatment options. So I am very aware that I’m biased towards implant. So I tell patients that, look, I am biased towards implants, but let’s figure out what’s best for you, not what’s best for me. And I have this open discussion with patients, and this is something I learned from Otto Zuhr and Markus Hurzeler. They are good periodontists, and they are very aware that when we do one thing all the time, we get biased towards it. So we need to really have that separate mind which is not biased and think both ways. [Jaz]It’s like the saying where when all you have is a hammer everything looks like a nail and that’s been used a lot with a certain implant dentist who perhaps overzealously trigger happy with their implants where they could have been doing other modalities. So we need to give all the options that are appropriate. [Devang]I have had a situation where associates send a case to me and I say this tooth can be saved and they’re like, no, you can’t. And now I’ve went on and saved it because I do restorative treatment as well. But that’s something you need to really discuss. So I discuss with patient all the options, denture, bridge, and sometime I’ve done bridges like 90 year old, 91 year old needs a big bone grafting. Okay, just do conventional bridge. There’s nothing wrong with that, so that’s something we need to discuss. Then, we need to discuss, we need to see smile line, if obviously, if you see your first few cases, I wouldn’t recommend touching the anterior teeth.Although if the implantologist has done a good job, they are no different, because the impression process is same, if your lab technician does a great job. Then you can just literally go straight to finish. [Jaz]But if you are going to do anterior teeth early on, you got to pick someone with a low smile line. So when they smile, they don’t even show their papilla ideally, right? In the first few cases. [Devang]That was one of the criteria, but you need to make sure you give patient a mirror and see how they look at it. Because even though patient’s smile is low, they might pull their lip up and look, trying to look. And if that happens, that’s a high lip line case for me, if that makes sense. So you need to really also assess patient how they’re looking at their smile. Then obviously we need to look at the oral hygiene, whether patient’s oral hygiene is great, periodontal condition. This is something really important and many time implantologist misses that because they don’t have a restorative background. You need to look at the adjacent teeth. Okay, we need to look at the contact points. Sometimes the teeth are tipped. Can we correct that? There are restorations which are sticking out which will create a point contact and I want sort of a surface contact if that makes sense. Can I adjust that? So we need to look at all this adjacent teeth. [Jaz]You’re talking about like amalgams, right? Amalgams with ledges, amalgams with the old amalgams, which are still perhaps don’t need to be replaced, but just actually polishing them, getting a red diamond and getting the right contact surface. [Devang]Yes. So that’s something which I even miss sometime, time to time. And I wish that we had technicians who would. Because sometimes, when I do my own wax up, I really, I’m sitting in calm. There’s no patient. I’m thinking, I wish the technician would take a lead on them and then when they receive a walk, it’s like, Dev, you could do with a little bit bonding on the mesial aspect of central to get the mesiodistal dimension perfect of both the teeth. They’ll just restore the gap. But if we get some sort of a guidance, then that would be really helpful from technician. And then this is also come under secondary treatment. So you need to always look at whether patient need any whitening, whether they need any ortho because you can’t. It’s very difficult to do ortho after you’ve done implant. It’s not impossible. It’s tricky. All patients need any full mouth reconstruction. And this discussion needs to happen before patient has implant, even if you think patient is not going to go ahead with it. So even if patient says, no, I don’t want full mouth reconstruction, at least you need to have a discussion because guess what I’ve replaced someone’s-, a few dent-, a few implantologists’ implants, implants were fine, crowns were fine, just patient needs full mouth reconstruction, patient wasn’t aware of that. [Jaz]I’ll ask you a tough question Devang. Obviously, you teach full mouth rehab and you’re also teaching restoring implants for GDPs. I think, and see if you agree, I think if you’re going to go on a learning journey with you, that you should learn full mouth reconstruction first, then implant, right? Because if someone’s lost vertical dimension, they’ve got tooth wear issues, generalized, and the teeth are really, really short. And then you put an implant in there and try and conform in that bite. Really, they would have benefited from opening the vertical dimension. It’s much better to plan the implant from that new occlusal position, right? And same with orthorhontics. Or have a eyesight on assessing which patient need full mouth reconstruction. If you don’t do it, refer to your colleague who does do full mouth reconstruction, if that makes sense. So, because I understand learning full mouth reconstruction and implant can be quite daunting like together and expensive because learning any of those two skills is not cheap. [Devang]But yeah, you need to have an ability at least to plan those cases when you are doing implant restoration. Then you need to look at the the space whether you have enough space because for restoration and that really matters. If you’re looking at interage because sometimes posterior teeth I actually saw a case two days ago one of my mentee showed me and this was on a full mouth construction we do a two weekly sort of case discussion and someone literally placed an implant on lower right seven recently two months ago implantologist and patient got collapsed bite patient, upper right seven is touching, healing abutment of lower right seven, which is equigingival. So they are now considering explanting that implant and giving a patient refund and then doing another implant. So I mean, I had few thoughts about that in the sense that you could use the implant to literally intrude the tooth. If implant fails, fails. But at least you’re doing something with that implant rather than explanting it.But what I’m trying to say, the implantologist did not see, they just saw the bone, saw the edentulous area, placed the implant really nicely. But did not check the occlusion. [Jaz]Which is why it should all be restoratively driven. And that’s the basic thing. When the patient bites together. [Devang]Yeah, and that’s why I feel genuinely that as a general dental practitioner, it’s our responsibility. Because implant surgeons, they’re trained for surgery, not trained for occlusion or anything like that. So I don’t blame them. It’s our responsibility when we refer a patient to tell them that, look, this is the case, there is no inter-arch space. A patient will need something else doing or don’t refer a patient until you sort that out, if that makes sense. So we need around five millimeter from gum to the cusp tip, at least space for the posterior teeth. You could do clever tricks and you can do alveoloplasty and you can do all sort of stuff to do that. But and I actually recorded a “supra erupted teeth” podcast episode. So that covers it a little bit more in there. [Jaz]What about mesial distally? [Devang]Mesial distally depends on the tooth. Okay. So, and obviously how tall is, and you gave a really good example of the lower central. I completely in agreement with that. So if you have one lower central incisor missing. then you need to decide, okay, you can’t really place an implant without damaging. Having said that I don’t see that many cases where just one incisor is missing is usually perio or some issues where at least two of them needs to go. If that’s the case, even then I do tooth to tooth resin bonded bridge sometime, because placing implant right in the middle where most of the time other incisors are not good bone support either. I just do that and then when the two laterals fail, then you can do two implants on laterals and replace four teeth and that’s more predictable with implant. So that’s kind of you need to assess, but generally you need to assess for the rest of the teeth. Mesial distal space, if you have enough. Now, if you’re placing, let’s say, whatever sizing plan you’re placing, you need to add three millimeter to it. So if you place three- [Jaz]Let’s make it very tangible, Dev. Like we could talk about every single tooth of the arch and then we won’t have time to record the other steps. So let’s say we’re doing an upper first premolar. Let’s just go with run with this one example and go deep into this one example. [Devang]What is the width of the premolar, that particular premolar? [Jaz]Well, actually, I’d like to know for you, what is the minimum that you want? And at what point does it become one and a half units? And then you’re struggling and there’s going to have to accept aesthetic compromises, you see? [Devang]Yeah. So basically for premolar, I would want ideally to place around 3.8 millimeter width of implant. It depends on the system. Yeah. So if you’re placing Ankylos, you have 3.5, which is fine for premolar. If you, I’m placing Bio Horizon. So you, at the moment, so I placed, I’ve used all, but right now I’m using Bio Horizon where it’s 3.8 is the size. So that’s the minimum I would want to use. And then you need to add 3 millimeter on either side, because you want 1.5 millimeter safety distance between two teeth. Now I have encroached that safety distance in past and everything’s fine. So, you don’t need to panic too much. Even if you think the space is a little bit tight, maybe half a millimeter, you can still gain consent from the implantologist, let the implant surgeon decide, but generally 3.8 plus 3, 6.8 millimeter width you want between roots. Okay. And if you have around three millimeter on either side, then it almost becomes a molar. Now. If, let’s say, two premolars, which are next to each other missing, that’s a little bit tricky scenario because sometimes you can’t put two implants together. Remember, between two implants, we need three millimeter distance. So now we place it, we need six millimeter, just a space, plus whatever size implant you use, two of them. So many times you may decide to have a cantilever bridge, which is not my favorite option. I prefer if there are two teeth missing, two implants and two teeth. But I would rather do a cantilever than put two implants next to each other very close together and then make a problem with that. So that’s how I make a decision. [Jaz]Implants are like trees. They want space. I don’t know, some famous implant surgeon said that once and I heard it. And so I like to, that’ll be my one contribution to this episode. Implants are like trees. [Devang]Yeah, so you need to really make sure that they have space, basically. Okay. They like breathing space. [Jaz]Yes. Whatever size your implant is, add three millimeters. That’s how much distance you need between the roots. And obviously you’re looking at between the adjacent teeth as well. Make sure for aesthetics that you plan for it. Often a wax up may help you in such scenarios. What more do you want to add in terms of the assessment before we move to stage two? [Devang]So assessment stage, quickly, you need to also make sure that you have planned for temporary or provisional. When you are doing these kind of planning these cases, because if it’s an anterior case, even premolar, some patients don’t want to go without, so my go to method is, used to be Maryland Bridge or resin bonded bridge. The problem with that is they can come off, and if I’m working in 11 different practices. It’s a nightmare. So also what I’ve seen is I’ve used to use for canine. So if lateral incisor a lot, and if the resin bonded bridge, if you use it for a long time, some of my cases, like if I’m doing autogenous block grafting and soft tissue grafting can last for 15 months. Maryland or Resin Bonded Bridge put on high for 15 months will create a space when you remove it. So the canine guidance gone. So I now use most of the time Essix retainer with the tooth. The problem with that is patient can’t eat on it. So I give them a denture but not to use it straight after surgery. So that’s something you need to assess. Then you need to assess occlusion. We discussed that, the guidance. You need to really have a vision as to, after you finish the treatment, what type of occlusion patient’s going to have? So if you need to add canine rises to miss the implant, you need to do that before the treatment so that you get, you have the occlusion which is optimized. And then, of course, as I said, diagnostic backups. You need to make sure. that you have done diagnostic wax up in order for you to plan the treatment properly. [Jaz]Is this mandatory? Do you think this is a mandatory step with the dentist who’s starting to do a restorative implant? [Devang]If they’re starting, yes. I think it’s, I’m not there to make regulations. I can tell you that I don’t wax up all my cases. When you place over a thousand implants, you can really assess if the tooth is bound, that’s the simplest case to place implant because you’ve got the reference from either side. I do get waxed up when there are more than one implant I’m placing. So if I’m placing two implants next to each other, then you need to know exact distance you want these implants to be placed in order to get the good restorative. But if you’re starting, I think you would be better covered if you have done diagnostic wax up or if you’re doing surgery then had a surgical stent made up. But if you’re restoring that, at least have a diagnostic wax up done and gain consent from patient. [Jaz]Okay, great. Well, that was a whistle stop stall of assessment. Let’s now get to the real deal, the meat and potatoes of restoring implants. Absolutely. [Devang]So now we’re coming to step two, where we are ready to take Impression. So what will happen is that once you refer to your case, in which I would recommend you plan with implant surgeon, not just refer the case, ideally stay within that consultation appointment, plan it together, and you learn more planning process and how your implantologist think, because everyone thinks differently, that he or she will place an implant and send back. And do a exposure of the implant, send back the case to you, where you will see a healing abutment, which is in the implant. Now, healing abutment could be customized, so they may have customized the healing abutment to give you nice form of the gum, or it could be a stock healing abutment, which may look like a silver sort of a metallic color and would be round. [Jaz]For an upper premolar. What would typically come back with it? Would a custom one come back or would a standard one come back? [Devang]Usually it will be cost. It’ll be standard. [Jaz]Okay. [Devang]So you will have a standard healing abutment. Now, again, you would have known which implant system your implantologist uses. As I said, I would recommend that you observe at least five cases restoring that in person, restoring it before you start just jumping and start restoring the implant cases so you can log that you observed. And ideally for at least my mentees, I tell them that I would observe their five cases. So at least 10 kind of observed cases before they go on themselves. It’s a bit of an overkill, but I think that’s the safest way to learn. So now once you get the back, you will have a healing abutment. Gum should have healed nicely. Sometime if the sutures are still there because they want you to take the sutures out and take the impression at the same time, which I tend to do if it’s a simple exposure. Then you just need to take the stitches out. Make sure the gum’s heel looks pink. Sometime if the implant surgeon has done soft tissue grafting, it will take a while before it heals. But most of the time, as an implant surgeon, I only refer a patient back to a dentist once I know it’s complete, it’s ready to take impression, basically. So that’s where you are. Now, when it comes to taking impression, you have three different ways to take impression. Okay, so you can take impression using closed tray method. You can take impression using open tray method and of course you can use digital impression as well. Okay, closed tray method is the least favorite method of mine because the way it will work is you put something, you take the healing abutment out, you put this impression post in the implant and you take like a normal conventional impression like you do for crown and bridge. And what would happen is whatever you put the impression post in the implant will come out. in your impression. [Jaz]I’m asking very noob questions here, right? So this is like, a very basic level, but the impression post, when it attaches into the implant, it’s not like fixed. It’s allowed to come out, come away in the closed tray. [Devang]So it’s not screwed in. So for closed tray, if you’re not screwing in the impression post sometime, and this is where the confusion comes, right? So some implant system has screwed in post and you will have a toggle on top, like a small insert on top. So you only get the insert picked up in the impression, not the whole post, but you will have to see, I’m just giving you a general idea because it’s difficult to cover every implant and how they work. But generally the concept is you take a normal impression and this concept was developed because to make general dental practitioners life simple, plus to do an open tray impression, you need to be able to put the post, the screwdriver, everything in patient’s mouth. And if you’re doing upper right seven, you might not have access to do all that. That’s the reason closed tray was one of the benefit of closed tray impression. Putty wash. Yeah. Just normal crown and bridge material. You could use ideally Impregum which is more rigid, but I do putty and wash most of the time to be on, because not all my surgeons, they don’t have impregnum. So coming back to the issue of you’re not being able to access upper right seven is that if the implantologist has managed to place an implant, which is basically you have a driver, implant is on top, place all that in upper right seven, then there’s always patient has immediate effective mouth opening for you to take open tray impression. So in last 13 years, I probably have done one open tray impression, sorry, closed tray impression. So now, I almost 99.9% take open tray impression, which is more accurate. [Jaz]Why are you so against closed tray? I’m still trying to suss out what is it that you don’t like about closed tray? [Devang]Because what will happen with the closed trays is, you know the thing you picked up in your impression? Then someone needs to manually put the impression post, click into that impression. Now when you’re doing all that faffing, you can move stuff. It’s easy to move. And make the impression inaccurate. And one thing we want to know, we want to do is when we take implant impression, we don’t want our impression post to move. We want it to be rigid. Because implant is fixed in the bone. Few microns here and there, the crown won’t fit very well. [Jaz]So just describe open tray, because what you haven’t mentioned yet, but I’ve done it before is, it’s like, do you always need a special tray? Or can you use a stock tray for these? [Devang]No, you can use, I use stock tray most of the time. Unless I can’t find a stock tray which fits in patient’s mouth properly. Okay. So when I put the, you select the stock tray, I select the biggest tray I can fit in patient’s mouth because I want material thickness, right? So you want thicker material in order to pick up the implant. So it’s much secure. Okay. So let me go through step-by-step process of taking impression. Okay. So once you have your healing abutment, patients in the chair, you need to, before you do, you see a patient, you need to make sure you have all the components. You have appropriate impression post. You have all the drivers you need for the impression. Having a short driver is helpful because sometimes it can get a little bit tricky. If you’re using a driver first few times or ideally all the time, you need to floss it just so that you don’t drop it down the patient’s throat. So you kind of have secured it. So make sure that you check because every implant system may have different impression force posts for different implants. So check what implant it is. Check whether you have right post and make sure you have right components. Once the patient is in the chair, you will take the healing abutment out. I always irrigate with chlorhexidine to make sure that before I put the impression post, I’m not really putting anything in there. My impression post will be in the chlorhexidine as well. I pick it up, put the impression post, try a tray in patient’s mouth and see where the impression post sticking out on the impression tray. Use a straight handpiece or a fast handpiece to create a hole. So then it sticks out of the impression tray so I can unscrew it once the impression material set right. My nurse would then mix the putty and I would squirt some light body around the implant and occlusal surfaces of all the teeth. I will then place the impression tray and quickly find the post. It’s really important that you find the post. Otherwise, if your impression is covered, the post is covered by your impression material, you can’t unscrew it and the impression won’t come out. [Jaz]So just to make that tangible, like once you’ve got the, you’ve drilled the hole, like you said, you try the tray and you see where the impression post is prematurely hitting the tray, right? And then that’s where you drill the hole and now the tray can seat fully but once you’ve got the putty wash in. That’s all going to get covered in impression material and it’s about just searching for it with your finger. Is that what you mean? Right? [Devang]Exactly. Yes. So make sure you create a bigger hole than you think you’re going to need because the tray is not going to always go straight in that position. So make sure you have a little bit leeway and then you’re with your finger. Really you press in the putty where you created a hole to palpate the tip of the impression post. Once you’ve got the tape, I would keep my finger pressed there so that the material, impression material doesn’t cover over while setting and then let the impression set. Then I’ll use a straight probe to flick the impression which is there on the screw access hole because you know there will be some impression material in the access hole. Straight through, flick it out and then unscrew the impression post. Now, you need to make sure it’s completely unscrewed before you yank the impression out of patient’s mouth. The way to know that is when you’re unscrewing something, anything really, and if it’s completely unscrewed, it will click. So because the threads are jumping, right? So if you’re reversing, if it’s clicking, that means it’s completely undone, basically. Take the impression out. [Jaz]I’ll ask a question, another silly question, if you don’t mind. Is this impression post completely cylindrical. [Devang]It has notches and it has small grooves. So you can have the impression sort of get. Is that what, is that the question? [Jaz]Well, my thing is, I’m imagining now, this is years ago since I last did this, but if I am twisting and unscrewing it, then isn’t the impression material getting distorted? [Devang]No, so there’s a screw within the screw, right? Impression post has a hollow channel. [Jaz]The screw within the screw. [Devang]Yeah. There is a hollow channel. So impression post doesn’t move, but the screw under inside moves, same way you fit the screw, retain crowns, right? So the crown don’t move the screw inside the crown would sort of engage. [Jaz]Got it. Now I’m with you. [Devang]Cool. So, now you’re taking the impression out. I would irrigate the area with the chlorhexidine place, the healing abutment in which was there in the chlorhexidine back into the socket, right? Screw it, screw it back in. You don’t need to torque, and do not torque the healing abutment, just hand tighten and don’t use a torque wrench. Now, some people like to take x ray when put after placing the impression post just to make sure it’s seated properly. I don’t because nowadays impression post comes with the definite seating. So, if it’s not in a definite position, it will not seat and you will see it click most of the time and that’s how you would know that it’s seated properly. However, if you want to really take an x ray, then by all means do an x ray to understand whether it’s completely seated. Now, one thing we haven’t discussed is there are two different types, two different main types of connection inside the implant. [Jaz]Before we get to that, if you don’t mind, because this is a really important conversation coming now. So let’s just finish off on the impression for the newbie dentists, really new in the world of implants here, which is what we’re targeting at the moment and helping the Protruserati out who’ve never done this before. You don’t need any retraction cord. And is there usually a bleeding that you need to deal with? So this is what makes usually this kind of stuff easier than a normal crown, right? [Devang]Yeah, generally there is no bleeding. There is no bleeding when you take the healing abutment out. You may see a little bit of bleeding maybe, if the gum is still a little bit raw from the surgery, but no, generally there is no bleeding. And if there is a bleeding, you don’t need to worry about bleeding. Even, let’s say you take an impression, and you know the impression pose where it connects into the implant, and you tip your impression, and you see usually crown, when you do the crown impression, you want to see the margin nicely. You don’t need to worry about all that because if the margin is slightly uneven, some of the material is not a little bit flowed, it’s okay because technician can figure that out. It doesn’t, as far as you can, you’ve got the connection, right? The impression post seated completely in the implant. That’s all we want to capture. So it doesn’t have to be like a crown prep and that’s where it is. So you don’t need to use a retraction cord. I don’t know about you, but if I’m taking, let’s say two, three crown prep together. It never comes up in one impression. I have to at least attempt twice to get all of them in one go. [Jaz]So, air bubbles are forgivable as long as the impression post in general fits very precisely into the impression, right? [Devang]Yes, and it’s not moving. Okay, in the impression. [Jaz]So now let’s talk about this really mammoth topic of different connection types. Because like I said, as someone who once ventured into learning this stuff, it got overwhelming. The different connection types, different brands. So let’s try and make it tangible now for me and for the Protruserati. [Devang]Okay, sorry, just to complete the impression steps, you need to then take the opposing arch. If any occlusion, you need to record, you need to take the bite registration. But for single tooth, generally, you don’t need bite registration because you can hand articulate, right? And then once that’s done, you need to package it in a bubble wrap, put it in a box, and then, like a wood or cardboard box, and then send it. Don’t just put it in a bag and send the impression because you haven’t seen people collecting those bags. It gets, lots of things goes on top of it, right? So things can distort the impression post. So you need to make sure that is secure before you send it to technician. Now, before you do that, actually, you need to write a prescription, right? So you need to make sure that you’ve written a prescription to the laboratory technician, and that’s where all the connections and everything will come in play, right? So now you’re telling your technician few information, okay? So you are going to communicate with technician what you’ve just done basically and what you want them to do. Now before you do that, you need to know a few things, okay, about implants. So first is connection, obviously. There are lots of connections and it’s difficult to cover all of them, but there are two main connections. You have external connection and internal connection, which means implant is solid and then the crown goes on top of it and externally hooks into the crown. Whereas internal connection implant crown will literally go inside the implant. So there are two different connections. Internal connection is the one which is most widely used. So there is a very high likelihood for a single crown, you will receive an implant with the internal connection. [Jaz]I’m a simple guy, Devang. Listen, I’m a very simple guy. Am I, is it an oversimplification if we call an external hex connection, an outie, like belly button, an outie and an innie, would this analogy work? [Devang]Yes. So you have the internal connection, like a belly button. So, you go inside and that’s the internal connection. And the reason is that it’s a bit more secure for the screw. Okay. So there’s less screw loosening with those connections, especially for single crowns. Generally for single crowns, you will not see external connection implant nowadays. [Jaz]Okay. [Devang]Now we decided, okay, we’re going to mainly dealing with internal connection implants. There are two types of internal connection, main ones. One is a butt joint, like surface on surface connection. And the other connection is a conical connection, like cone within the cone. [Jaz]Okay. [Devang]Okay? Now, if you imagine, surface to surface connection, it’s easy for you to know if it’s not seated properly. Like, if it’s not completely seated and there’s a millimeter gap, if you take an x ray, you will see a black margin. Does that make sense? Because there is an air in between. [Jaz]This is the butt to butt. [Devang]Butt to butt. So it’s a butt joint connection. You would know easily if your crown’s not seated properly. Whereas if you have a conical connection, difficult to know exactly whether the cone is completely seated or a few microns off. Okay. So that’s the difficulty with conical. However, conical connection gives you more secure connection than butt to butt. Because with butt to butt, butt joint connection, if the screw becomes a little bit loose, It just starts wobbling all of a sudden. Whereas with the conical connection, if the screw becomes a little bit loose, the conical connection itself will protect the crown. So you get less screw loosening with that. Plus, this is for implantologists as well, that it gives you nice emergence profile and it prevents your bone. So bone stays better. So I prefer personally, conical connection. So when I use Bio Horizon, I prefer CONELOG implants in there because it has a conical connection. Does that make sense? [Jaz]So we like, yeah, it does. So we like sticky-innie implants, with a cone connection. But like all of this stuff, like for example, you said you use Bio Horizons. Do they have a Bio Horizon sticky-innie? Do they have a Bio Horizon sticky-outie? Or is a brand generally one type of way? So you can get every, it’s like a candy shop. You can get every single combination. [Devang]Yeah. And unfortunately, you’re not going to be the one who will select that because your implantologist would have selected it. You kind of mercy of them, whatever they select, you need to restore it. Right? So I have made a lot of my associates life difficult when I, by selecting some of the implant system, but that’s how it is. They all have ins and outs. They all have problems, but no system’s perfect. So it’s not that if you get a butt joint connection, it’s not good. You just need to know what it is and how to assess it really. So that’s one thing. [Jaz]But this is a feature of the implant that’s already in the patient’s mouth. You are just, A) finding the information of that implant, identifying it correctly. So this is something that your implantologist, when they send it back to you, hey, I used a Bio Horizon 3.8 sticky-innie internal hex, with a cone. Make sure you know this information. Is that kind of how it works? [Devang]Yes, exactly. So I always send my associate, someone who’s referred cases to me, a log sheet with the sticker because I might make a mistake in writing what connection it is. But generally when we place implants, we use a sticker from that implant to put it on a paper. I scan it and just send it to them. So there is no ambiguity as to, no miscommunication. And that’s something I give the patient at the end as well. [Jaz]Now Devang, before we continue again, I’m going to suggest, because I’m really enjoying this, I’m going to suggest we nail this part one. Right? Like really just slow down a bit. Let’s nail this part one. I think let’s re record for part two one day. But I’m just letting you know that I’m really, I’m learning a lot here as well. And I think this is really going to be like, for a lot of people new to implants, it’d be like, wow, the sticky-innie, sticky-outie. This would be really good for us, I think, if we just slow it down and keep finishing off part one, like we are. Is that okay with you, buddy? [Devang]Yeah, yeah, that’s fine. That’s fine. Yeah, no worries. [Jaz]Okay, cool. Okay. So now you know which type of implant it is. And then I guess the impression post will also depend on that information as well, like the impression post that you select? [Devang]Exactly. So you would have known this information kind of beforehand anyway. This is not the time you would know what, this is too late kind of. You would have known when you receive the patient, all the information, because you need to have all the components ready. This is for you to tell your technician, right? But when you tell technician what implant it is, what platform size it is and what sort of connection it is, implant, the laboratory technician will know, but I’ll come to that in a minute. So first thing you need to know what connections implant has. Okay. The second thing you need to know is screw retain crown and cement retain crown. That’s a big, two big different camps, really. Some implant, they are like truly believe that cement retain is the way to go and some people believe screw retain is the way to go. I’m in a screw retain camp. As I said, I’m biased. The reason I prefer screw retain because it’s easier to manage if there is, let’s say a patient doesn’t like it. You fitted the crown and we all have this patient sometime to time to time where you fitted patient like yeah, everything’s good, perfect, and then you get a text message because all my patient has my mobile number. You get a text message or when patient come for a review appointment like mmm. I don’t like it. I want to change this. Now, if you have used a cement retained crown, which I will go through the process in the next episode, that it’s difficult to take the crown out and change it. If it’s a screw retained crown, you can unscrew it, send it to the technician, and change it. Future complications, like if something’s chipped or broken, if patient’s broken the porcelain of it. It’s easy to manage if there is inflammation around the implant. You want to take the crown out to assess properly. It’s easy to do that. So for me, and also the main reason I stopped doing it years ago, 11 years ago, doing cement retained is because there is a risk of pericementitis, which means that the cement can go into around the implant tissue and cause irritation and that can cause implant to fail. And this is a very well known, studied fact that many of the cement retaining plant fail because of this reason. [Jaz]Did you just say pericementitis? [Devang]Yeah, it’s just- [Jaz]Wow. Wow, I love this. [Devang] So it’s a made up word, but yeah, I think it’s been used quite frequently, not made by me. But I read it, but it’s not a proper, I think it won’t be there. [Jaz]Like I knew peri implantitis. Like was a first, like when I was a fourth year student and then someone said peri implantitis, me and my friend Clifton looked at each other like, wow, that this is a thing. There’s a word. And every time it’s like a running joke between me and him. But peri cementitis is like my new favorite implant term. [Devang]Yeah, exactly. So that’s the reason I don’t use a cement retained crowns and I do anything and everything and which will go in troubleshooting anything and everything to make my restoration screw retained crown. Okay, so let’s say there are two cement retained crown. If you are doing it, it will come in sort of two pieces. You’ll have abutment, which you screw into the implant, and then you have a crown which goes onto the abutment. Whereas the screw retained crown will come in one piece, where you literally screw the whole crown into the implant. Why the channel not so the crown doesn’t move you have a screw access hole. So you see the crown into the implant is snuggly seats in and then you screw the screw it from the channel to make it secure. [Jaz]Is anything that we talked about previously because you mentioned about the internal the innie and the outie. And the butt and the cone does any of them predisposed to, oh, because you’ve used this type of connection, you can now only do screw retain, or you can only do cement retain, or is there still, like, you could still go either way still? [Devang]You can still go either way, yeah. So you’re not dictated by implantology, if that makes sense, or what implant it is. Generally, you can do either in either. There are some system, which you, like the Encode, traditionally, Encode implant system, you are, you were meant to do a cement retained and that’s how the implant was developed. But most of my Encode restoration where I placed and restored, they’re screw retained. So, there may be systems who were traditionally evolved for cement retained restoration, but you can still make screw retained restoration. Most of the system you can. I don’t see any reason why you can’t. Now, to make it even more complicated, the screw retained restoration has two different types. Okay. One type, which is the most favorite type for lab technician is you have a pre made abutment, titanium abutment. Okay. The technician will then cement in the lab crown on top of the abutment, create a hole so you can access the screw. Okay. So it’s a pre made abutment cemented with Panavia or some sort of a cement. The crown is cemented on top. Crown is created a hole and that makes one piece implant. Does that make sense? [Jaz]Is that also called screwmented? Or not ? [Devang]Screw Mented? [Jaz]My second favorite word in implant. ScrewMented. [Devang]I didn’t even know I’ve looked for that word and I could not find anywhere, but I know where I got that word from. But I’m sure there’s someone who said it. [Jaz]I saw it from Pynadath George. I saw him use it once on. [Devang]Yeah, so screwmentable crown. So, the screwmentable crown is basically cemented outside. Obviously with any screw-it-in crown, you need to make sure you implant in the right position, right? Because if you let’s say doing central incisor and the excess, the implant excess is coming through the buccal. You can’t have a hole on the buccal aspect. Again, we’ll discuss in troubleshooting how to overcome that issue. But, for now, just imagine the implant’s in a perfect place, and now you’re making a screw retained crown. Okay? So, she’s doing the screw retained crown. So that’s the one way to do it. The problem with this is that the stock abutment, or we call it Ti-bases, titanium bases. Most of the implant company would call it Ti-bases or a stock abutment. They are very, very small that somehow that the height is not appropriate so you have a big crown tall crown cemented on a smaller abutment and you tend to see some de-cementation of the crown over the time like you see in a normal crowns unfortunately as a dentist who is not in the lab you would know the height you would not know the height of the abutment because the crown is cemented. So when the crown comes to you, it’s in one piece. You can’t tell what’s the height of the abutment underneath it. And that’s something you need to tell your technician to send you a photo of the abutment height. I want to see the chimney height. So if I am using this type of crown, which I do now, I want my technician to custom mill the abutment of the chimney height. I want the chimney height just one millimeter shy of the occlusal aspect of the crown. So it provides the full support to the crown. Does that make sense? [Jaz]But these ones, like you said, they don’t, they don’t exist in the stock. So does that mean they have to make it? [Devang]So it’s a custom. Yeah. So it comes in a custom screwmentable crown. So it’s a sort of sub sub category. Not many technicians do that for titanium. Okay. And that’s why the best way to do it, which I’ve been doing until now is always have a custom abutment. Don’t use a stock abutment. So I always use custom abutment until I found a technician who can turn the titanium. Apparently that you can’t mill the titanium. You have to turn it. It’s a different procedure to turn the titanium. But until now I’ve used a chrome abutment because chrome is easy to mill and you can put a porcelain on chrome, like PFM. So it’s genuinely one piece implant. There is no like cementation or anything. So the technician or a company milling center will mill the abutment to your specification, to the height, width, whatever you like. It will come to technician. Technician will then put a porcelain on top and make one piece implant. And that’s how implant, screw-retain implant started. And we tend to use to call it a UCLA abutment because, or UCLA crown, because it was there in America, UCLA university. That was the university started doing that first. So we learned as a UCLA, but it’s basically a PFM screw retained crown. Okay. [Jaz]So this is like, previously it would have been perhaps waxed up and the standard PFM way, but now it’s all milled, but now it’s all milled and done. Okay. [Devang]So when I did my training, we casted that and then did it. So I made it myself. By casting, we didn’t have a milling machine. So we casted everything. But now, milling is much more predictable, and much more better than casting. You get much less error, and marginal fitting is better. Problem is, that the custom abutment, if they are chrome, chrome oxidizes, right, over the time. So when you put chrome with the titanium, there’s argument, there’s no studies on that. but I’ve seen it, at least my 10 year old cases, if I remove the crown. You see oxidized gunk, you know the the process so which I stopped liking so this is me evolving really and that’s why I’m using now titanium because titanium to titanium is a better connection and better sort of for health wise as well biologically is better so I use that’s why titanium scrumentable crowns, but It’s turned, it’s custom titanium. [Jaz]But lots of dentists are still using the stock type. [Devang]Yeah because they don’t know, right? So I’ve done it. So I have, when I started my implant restoration journey, I used to tell technician, I want to screw it in crown. That’s it. And crown come out really nice, screw it in and then. You see, after three, four years, crowns start popping off because the cement’s failing. And then you see the size of abutment. [Jaz]Yeah, yeah. The ceramic is coming away and there’s a tiny metal peg left in the patient’s mouth. [Devang]Yeah, generally it’s a Emax or a Zirconia crown. So it’s a one piece crown cemented on the abutment. The whole crown comes out. And you see the abutment and think how the hell it lasted even four years. Like, it’s like small. Really, really tiny. So that’s something you need to know the difference between custom abutment, Ti bases, and chrome and versus titanium. Okay. Does that make sense? [Jaz]Okay. So this is really making sense to me and it is showing me a new, uh, light on in this entire thing in terms of the challenges and makes a lots of stent from a mechanical point of view. But in our lab prescription, if I was to summarize so far, you’re going to tell obviously which tooth it is. [Devang]I’m going to summarize it. [Jaz]Amazing. Perfect. [Devang]Okay, I’m now summarizing the whole thing, because I just want to make sure that you understand the basics when I’m saying what you need to tell the technician. So I’m just covering the basics to make sure you understand, or not you, but the audience understand what we are trying to do. So the first thing you need, you need to write few things in your lab booklet, but once you and technician work together very well, most of this will be kind of assumed. So technician would know what type of things you want. But when you’re starting, it’s better practice to write everything down. OK, so first you’re going to write down the type and brand of implant, what type of implant you use. So you need to write that down. You need to write down implant size and connection size, because just to give an example, BioHorizon has 3.8 millimeter implant with 3.5 millimeter connection and 3 millimeter connection. So by just saying that I have a 3.8 millimeter implant doesn’t mean anything. You need to tell technician what connection size it is. Does that make sense? [Jaz]I mean, it makes sense, because I’m accepting that this is the way it is, but this is a whole new level. So this is like, you’ve got the implant. You got the innie and the outie, but now you’re telling me there’s a connection. What’s this all about mate? Implant people, why are you making our life so complicated? [Devang]Yeah, they just want you to, I mean, and then there’s different screws you can’t interconnect and different drivers you can. It’s all a business game, isn’t it? I mean, but then I think I know why it started, right? So it started because probably there was Brånemark implant, one type. And then they say, how can we improve it? Let’s start something different. And then how can we, then people start, and then everyone prefers, I’m sure they’re like, in America, they use Bio Horizon, Bio Horizon is one of the biggest brand, and that’s a butt joint connection. They like, they love it. I don’t like it. Does that make sense? So I think industry is trying to cater everyone. And that made things a lot, lot difficult. [Jaz]This connection information, like that sticker that you said, which tells you if it’s a sticky innie, sticky outtie, why is the implant, would that also tell you the connection or is it something that you decide? [Devang]Yes, it will have the connection. So, it will have the details of the sticker, will have, so you can either just send it over to technician, technician know what to do with it. Or you write it down, if that makes sense. So you need to make sure that you got the written down. You then need to take, obviously, clinical photo for the shade. So you need to make sure what shade it is. If you have taken periapical radiograph, or your implantologist has taken radiograph, then it’s good to send that to technician because technician needs to know how deep is the implant and where the bone is in relation to the implant. When they’re making emergence profile, many of the technicians, they don’t know how much gum to compress so to get the better emergence profile. So it’s better for technician to have that radiographic evidence just to give some reference. Okay. So some sort of a radiograph with implant in place would be good. If you take a radiograph and you put the impression post that’s even better because they can sort of measure it from there. Then you need to mention what type of restoration you want the technician to make. Okay. So we discussed screw retained restoration versus cement retained restoration. So you want to tell technician that please make. Screw retain crown for this. Now you would have had a discussion with technician, whether you want them to make screw mentable or UCLA type crown. Okay. You need to tell- [Jaz]So prefabricated versus custom, right, in a way? [Devang]They both are custom, at least for me, because I wouldn’t recommend Ti basis, stock abutment, just no, no, but screwmentable, as I said, you can have custom abutment, but titanium and titanium, you can’t put porcelain on it. So even if the titanium abutment is custom, you have to still cement the crown because porcelain won’t stick to titanium like PFM crown. Does that make sense? So you can’t really fire the porcelain on it. So you need to tell the technician what it is. For the first few time, I would advise you to ask technician to send you photos of the abutment before they cement the crown. So then you understand exactly what they’re doing. OK, and then if there is any other specific detail, you want either side of the teeth to be adjusted or you want your technician to know what is the size of the crown. Do you want your technician to tell you or dictate? Would you benefit from doing something like a restoration to either side of the teeth to get the better aesthetics, better contact point? Because sometimes, as I said, the amalgam sticking out and you missed it. You need your technician to guide you with that, yes, it’s a faff you have to take a new impression and all that but at least patient gets a much better restoration for rest of their life at least until the rest of their restorations life if that makes sense. So that’s something you need to tell and then obviously you need to transport this securely as I said in a box with a bubble wrap to technician. Now we haven’t discussed when we discussed the impression, a digital impression. [Jaz]Right. Let’s talk about that because that’s the final thing I want to talk about before we do part two. But before we get to digital, a little bit, a few more points on this prescription. I think this is being very useful for the Protruserati who are thinking about it for the first time about writing their prescriptions. So just summarize. We’ve got the sticker information and you’re asking for a screw retained ideally. Now, but you mentioned a really good scenario where if you’ve got a central incisor and the palatal bone is often more available. And so the implant is coming out facially. It’s like pointing at you. And therefore, if you did a screw retained, you’d have to put a composite on the buccal and it’s going to look ugly. So therefore, in that scenario, you might go for a cement retained. Am I right in saying that? [Devang]Nope. Now there is a suspense for the second episode. So I’m going to cover that in the second episode, how to manage these kinds of scenarios. So I don’t do screw retained. I don’t do cement retained, as I said, in 11 years. And I made a lot of messes, I’ve placed implant where it shouldn’t, not in the right direction, let’s say, and I have recovered from it. So I will share with you how I did it. And what are the options? But yes, cementation would be one of the way to overcome that. [Jaz]Okay. But we don’t like this and I like that. So I like knowing that we’re super pro screw retain, so fine. So you’ll ask for a screw retained implant crown. One question I’d had though is. Let’s say we’re going for this, not UCLA approach. Let’s say we’re going for a custom titanium base, and then the technician will screwment it. So they will screw your crown on top. Is there any guidelines where, whether if Emax or Zirconia or any type of restorative material is your restorative material of choice? [Devang]Studies have shown that zirconia, poly zirconia has a better attachment of long junctional epithelium. So if you put a subgingival polycon, yeah. So it’s much better connection. So, yes, I prefer polished zirconia for that. And then if it’s aesthetic case, then it should be, it would be layered on top, if that makes sense. So it’ll be layered zirconia for the coronal part, but subgingival. It will be polished just as zirconia monolithic. No layering monolithic. Yeah, no layering That’s my material of choice. But yes, if i’m doing let’s say Emax veneers or crowns, then I may select Emax crown for implant as well, just to match the cosmetic or aesthetic aspect of it. But I generally tell technician, like, can you match it with the zirconia? And if they say yes, then I’ll still go with zirconia. [Jaz]Excellent. That’s really helpful. And it perfectly. But if we’re going to go for the UCLA approach, and then they’re going to custom make this metal abutment of the right height and size. And then you said that we can get the porcelain to bond and fuse to make it like a one piece thing. Does that mean now we have to use a certain type of material and we can’t use Emax and Zirconia anymore? [Devang]No, we can’t, unfortunately. So with UCLA type abutment, we have all the limitation what we have with the PFM crowns. So the aesthetic I find with UCLA type abutment is always tricky because technician has to mask that metal and the porcelain, because it’s feldspathic porcelain it needs to be fully supported. So you can’t have a thin metal and a big bulk of porcelain because it will fracture. So you can’t build beyond it. And that’s the difficulty with PFM crowns. Even though you prepared a lot of preparation, technician can’t just have a thin metal and then lots of porcelain because it’s weak. So an aesthetic is my prime concern. I always go with screwmentable crowns because I have much better control over aesthetic. [Jaz]That’s amazing, and just reminds me of, and this is general restorative dentistry, it reminds you of me being on a consultant clinic at Guy’s Hospital. It was Mr. Saravanamuthu, and we were going around patient to patient, and this patient had this crown, just normal crown, not an implant crown, and the porcelain was chipping away, and then he goes into like viva mode, and he starts asking his questions, and he says, why did this crown chip? And we’re saying, oh, not enough porcelain. There wasn’t enough porcelain here. He goes well not enough porcelain or too much porcelain and that made me think oh, wow okay, actually it was too much porcelain not supported by the metal underneath hence why it fractures It really changed my thinking is very relevant to exactly what you said there. Let’s now cover, Devang, if you don’t mind, digital. And when did you move away from impressions and to digital and what are the nuances of scanning for implant crowns? [Devang]So I had a, I use a Medit scanner. I bought it myself. So I’m now an owner, but my practice already had a scanner. So when I was an associate as well, I still am, I have a medic scanner and I had it in my car or with me for two and a half years. And I just started using it like six months ago. The reason being is that scanning it’s easy for us, but we are leaving, we are giving a lot of control to technician and finding a technician who really appreciates that does really good job was very hard. I scanned now and then, and I had a very difficult work coming back and not great. So now I found a technician, which I’m working for, but six months is still pretty soon, but I’ve got a couple of technicians now who I work for and I’m kind of happy with it. And a lot of issues like movement of the post, occlusion, capturing the bite, goes away when you’re doing digital because it’s so much easier to do digitally, right? So, I’m doing now my, all my full mouth reconstruction fully digital as well, because it just makes sense to move away from the traditional. Although I still do time to time, depending on what I’m doing, conventional full mouth reconstruction, I do my own wax up. But now I’m doing more and more digital. With regards to implants, you need to have an appropriate scan body. That’s an impression post for digital impression. Okay. It’s called scan body and you need to have appropriate. Now, all the companies would have their own scan bodies. And if you’re technicians using company branded specific material, like a stock abutments, then you can use, let’s say, BioHorizon implant, you can use BioHorizon scan body. And you can scan. So generally it would work is you would take the healing abutment out. Let’s say upper right five premolar, take the healing abutment out. You scan in medit, that’s how it works. You scan the jaw without anything. Then you put the scan body and scan that section and the medit will integrate that with the full jaw. And then you do the rest of the scanning like you do normally. You take the impression scan body out and check the bite and take the bite as well. So that’s the scanning is pretty simple. [Jaz]I mean, this sounds really easy. I mean, there’s no gooey stuff. There’s no open tray. There’s no closed tray. This sounds ideal. [Devang]So easy. And then you need to obviously send it to technician and it’s all done digitally, as you know, so you can write down in your prescription what you want and goes with the patient, the technician. If you’re doing two implants next to each other. That’s even better because generally, traditionally, if we do take impression for two implants next to each other, it’s a lot of faff. We need to connect them with the material so that they’re rigid. Then we need to separate them and reconnect them because connecting materials shrinks. It’s a lot of faff. With the digital, you can just take impression because they are kind of, they’re not going to move, if that makes sense. So two unit is like two implants next to each other is also fine digitally. So digital impressions. It’s pretty simple and safe, as far as the technician knows what they’re doing. [Jaz]But if you’re learning implants, if you’re the beginner, like the case of the example we’ve given you throughout this episode, if you’re doing your first premolar, what would be your advice? Like, for me, like, I’m very digital now. So if I’m starting to restore implants, just because I am digital, would you say, okay, because you are digital already, just go for the scan bodies? Or do you think I should take a step back and do impressions? [Devang]No, just scan it, scan it. Just make sure you and technicians are on the same page. Find a technician who has more experience so they can guide you. So my technician, when I started, I remember [name unclear], he’s from Italy. So I used to send my work to Italy because I got to know him very well. No, because I knew him from Fouad Khoury’s course, which I did for blockcrafting. So I sent him, it was really expensive, but amazing, because he would dictate, he’s like, yeah, your prep’s not good or like he would not fear criticizing dentists and I want someone to criticize me so that I can improve, right? So, and he would say, look, Dev, add some composite on this. He was the only technician who I found who would tell me to do stuff, like do it this way, like kind of, I would, I would, I would not agree all the time. Most of the time would be right. So if you find a good technician, scan it. It makes your life so much easier. And that’s the technology is going and digital is the way forward. So yeah, scan it as well as you and technician, what are you doing? [Jaz]Brilliant. Now just give us a flavor of what we’re going to be covering in part two. And if you do mind, I’ve been thinking of the title of this episode series the whole time we’ve been talking. Is it okay with you if we call this a two part series and I don’t mean to offend anyone, I just feel like it’s very relatable, because like, I’m an idiot, I’m very basic, so if we call it, the innie, the outtie thing, as we were discussing, can we call it an Idiot’s Guide to Restoring the Single Implant? Do you mind? [Devang]As far as you think, you’re not offending anyone, that’s all. People tend to get, they offend quite easily, don’t they? But yeah, as far as you’re happy, I’m happy, I don’t mind that. [Jaz]And assume that the Protruserati know that I’ve got their best interests at heart. And actually the questions I was asking was genuinely for me, like, wait a minute. And I was, when I was interrupting you, it’s because generally, like, I need to be told, like, when it comes to implants, like I’m five years old and I found that the Protruserati usually thanked me for this and they don’t hate me for it. So let’s go with that. Brave decision. Guys, let me know in the comments below, was this the right choice to call this a title an idiot’s Guide or are you offended? If you’re offended, I’m sorry, but grow up, grow a pair. So then what are we covering? I’m not doing the idiot’s guide to restoring this thing. What are we covering in part two, my friend? [Devang]In the part two, we are covering, which we are both very passionate about, which is occlusion. As we’re going to cover occlusion, we’re going to cover fitting of the crown and occlusion, maintenance of implant and really troubleshooting because when you start I remember this quote from Mike Tyson, that everyone has a plan until you get punched in the face. So until you get punched in the face, like once you get the problem, you think everything’s fine. Does that make sense? So we’re going to discuss about some of the problems, some of the mess I created really over this 10, 11 years. And how I learned from it. So you learn from my mistake and hopefully you won’t do that again. So I’m excited. [Jaz]Standing on the shoulders of giants and all that Jaz, amazing. Devang, are you going to cover the scenario where you’ve done your implant crown, everything’s hunky dory, and then a few years later you come back and now there’s an open contact where there wasn’t before. Are you going to cover that scenario? [Devang]I will. There’s not much you can do to be honest. [Jaz]You will now. [Devang]Yeah. I will cover it. [Jaz]Okay, because that’s happened to me where I’ve seen a patient and then food getting stuck there. But, and I’ve read that this is a common issue and it’s due to ages related changes. And you can explain about how to manage those scenarios. It would be great, so troubleshooting. I’m very much looking forward to that. Devang, thank you so much. I’ve got to pick my kid up from school. He’s finishing earlier today because of the whole last day of summer, but we’re going to get our date sorted. Thank you so much. [Devang]Thank you. Jaz’s Outro:Well, there we have it, guys. Did you enjoy the Sticky Innie, the Sticky Outtie? Try and really make it as basic as possible. Like, I find it so frustrating, right? These implants, they all come with different settings and different types. And this is the real big barrier. This is what makes implants and learning implants and restoring implants such a steep learning curve, right? It’s just getting your head around. All the different vast possibilities that you need to be some sort of genius to figure out the matrix and and hand on heart. This is what stopped me. I think one of the reasons it stopped me from pursuing this in the past. I just felt it was just too complex. It was just too much going on. And I just liked some other areas of dentistry, which I do. And I’ve just gone all in with that. Maybe I’ll do implants and stuff in the future. But I hope you appreciate that it’s really important that we learn these things, right? Implants are becoming more and more common, so I hope you enjoyed learning about restoring single implants and the different nuances, and now you know what an internal hex and an external hex is as well. There we are. If you’d like to gain CPD, an hour and fifteen’s worth of CPD, get a certificate, have somewhere that you can put your reflective log in, which will actually turn up on your certificate as well, that Mari will email to you, then join the app, that’s protrusive.app, you can actually use it on Android, iOS. And the login also works on your laptop on protrusive.app. Or of course, if you’re watching on YouTube for free, I appreciate that. I still appreciate you watching all the way to the end. Thank you everyone for listening, especially the audio listeners. You guys are awesome. I’ll catch you in the next episode.

We speak with Dr. Pav Khaira, a total implant nerd, who shares 4 of his top tips for maximising osseointegration: Biological ageing: discover the time-sensitive nature of implant bioreactivity and its impact on integration (and how to improve the bio-reactivity of your implants) Mastering the osteotomy: fine-tune your skills in shaping the osteotomy based on bone quality and type Disinfection: explore disinfection techniques of the osteotomy Systemic factors: optimise early-stage healing and understand long-term immunological balance Don’t miss an upcoming exclusive live event on “Superosseointegration” on 15th and 16th September 2023 in London hosted by @Dr.Pav.Khaira – www.academyofimplantexcellence.com https://youtu.be/fBfnxubdgpc Check out PDP155 on YouTube Maximise the osseointegration of your implants and uncover the intricate relationship between the skeletal system and the immune system (known as osteoimmunology) and its impact on implant success. Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode:00:00 Intro01:19 The Protrusive Dental Pearl03:11 Dr. Pavandeep Khaira04:29 What is osseointegration?05:04 Osteoimmunology07:39 Early-stage failure09:52 Success and survival rates12:33 Biological ageing15:45 Decarbonisation for Implants21:18 Bone density24:10 Overheating the bone27:16 Disinfecting the osteotomy29:21 Systemic factors33:03 Superosseointegration36:58 Outro If you enjoyed this episode, you will love Why Should You Avoid Flapless Implants? – GF015 Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month? Click below for full episode transcript: Jaz's Introduction: We know that implants are a great way to restore an edentulous area. It is not a replacement for a tooth, because teeth are still the best, but the next best thing for a missing space at least, are IMPLANTS. Now, implants can get very complicated, different stages, surgical, restorative, but the very initial stages is all to do with ossteointegration, which is essentially, in a crude way to describe it, would be the fusing of the implant to a patient's bone. Jaz’s Introduction:Or as I like to call it, how long it takes for the implant to cook, so it’s ready to accept load. Today on the show, I’ve got Dr. Pav Khaira on again, he’s our resident implant expert and a titanium nerd, and he’s going to cover four techniques he uses, and most of these are very quick to act on, very simple, and something that you can apply straight away. One of them does involve you to buy some extra kit, but the reasoning is really solid, and it’s something I hadn’t heard of before, so it’s four ways to BOSST your OSSEOINTEGRATION. That’s the success rate overall, and the quality of your osseointegration itself. Like Pav taught me in this episode that most implants, when they’re placed, about 56% of the implant is covered by bone, or rather 56% of the implant is actually directly contacting bone. And with his techniques, he’s getting that much higher, which he believes results in a longer lasting, more successful implant. So he calls this all super osseointegration. Protrusive Dental PearlNow before we join Pav to reveal those four ways, I’ve got your Protrusive Dental Pearl. Now please bear with me because I do have an ulcer on the inner side of my upper lip. It’s a little bit painful, but the show must go on. And my son is home today because of school holidays. So I’m hoping he doesn’t barge in and have to record this all over again, but let’s go, let’s do our Protrusive Dental Pearl, which is not an implants one. I don’t do implants myself, but I can tell you is about COMPOSITE BONDING. Here’s a tip I picked up when it comes to anterior composite bonding. You need to evaluate what percentage of your appointment are you going to actually devote to the placement of your composite and what percentage of your appointment is going to be the finishing and polishing. And if you think about your last few cases, what percentage of your appointment was the placement. Well, if you’re like most dentists and certainly me many years ago, I would do like 90% of the appointment actually placing the composite and 9% of it checking the occlusion because that’s very important to me. And then you’re looking at the time and you’re running late and then you quickly, you know, finish and polish and you try and make it as shiny as possible in that valuable one minute you have left before your nurse starts giving you the eyes. And really, if you look at what the masters do and how they get wonderful results in their composite bonding, we need to really change this. So I was always advised 50% of your appointment length should be the actual placement of the composite. And the rest of the appointment should be, yes, checking the collusion thoroughly at the end, but a huge bulk of that will be finishing and polishing because that’s how you get a stunning, long lasting, unstainable result. And of course, if you nail those line angles and that secondary anatomy, even tertiary anatomy, you make it look more lifelike. So the way you can action on this tip is either you need to book longer for your appointment. So you got more time to do finishing polishing, which is such a crucial step, or you just need to be a little bit quicker in your placement and actually devote more time to getting it all perfect in the finishing and polishing. So less time placing, more time finishing and polishing. That’s the tip for today. Let’s join Dr. Pav Khaira for the main episode and I’ll catch you in the outro. Main Episode:Dr. Pav Khaira, the titanium nerd. Okay. You are Mr. Implants for me, you know that. And we bring you back again to talk about, I don’t want to ruin the surprise, but ossteointegration and then how you do ossteointegration and all the levels of details that you go into. You’ve done so many episodes of us four. So if anyone hasn’t heard of Pav, check out the dental implant podcast or listen to some of the previous ones we’ve done covering all sorts of things such as can you probe this implant to how to clean under your implants to finding your niche and dentistry. So lots of different implant topics that we’ve covered already. So if anyone hasn’t, for those few people that haven’t heard our episodes before, just tell us about yourself, Pav. [Pav]Jaz, thank you very much for having me back. I am a titanium nerd to the core and I’ve mentioned this several times, but you’re the one who inspired me to start the dental implant podcast. And I just, all I do is place implants, restore implants. I absolutely love it. And I just love studying. I love teaching. I love helping patients. I love helping other dentists increase their skills. So anything titanium related, my wedding ring is made out of titanium. My daughter got me a a chain for father’s day. That’s made out of titanium. Everything’s just titanium for me. So that’s why I call myself Titanium Nerd to the core. [Jaz]I love it. And today what we’re covering is Osseointegration, which you can explain what it is for the dental students. We know is how you get the screw to fuse to the bone. I’m sorry. If it’s said very crudely by a non implant dentist, but you say it more elegantly, but how to get your implant to, it’s fuse the right word? [Pav]I don’t want to get too technical about it because technically fused isn’t the right word, and effectively what integration is nowadays, we classify it as a controlled rejection of the implant but for simplistic terms, yes, let’s call it fusing to the bone, yeah. [Jaz]And this is something that if it fails to happen, it’s a heart sinking moment for a dentist and a patient. And we can find out, we can get an idea from you, what are the signs to look out for? At what point does this happen? So let’s say you place an implant and it fails to osseointegrate. When would that typically happen? And what is the number one cause of that? Before we then delve in to your multiple levels and layers of tips to make sure that we increase our percentage chance of osseointegration. So what commonly causes the downfall of implants? [Pav]So there is a concept now called osteoimmunology, which is an interplay between bone and the immune system. So this is why I called it a controlled rejection. Because what happens is, if you think about it in terms of fusion, the perception is that the bone fuses to the surface and then kind of like, that’s it, it’s like a cement post in the ground, you put the cement in, the fence post goes in, and the cement sets, that’s kind of like it for a very, very long time. So we know that that doesn’t happen is the body recognizes the implant as a foreign body. And it almost, it wants to reject it, but it kind of like encapsulates the implant within bone. And then there is then healthy bone around the implant. It’s aiming to contain the implant and not have it kind of like leach out into the body. So it’s a paradigm shift in its definition. But what that then tells us is there’s this balance backwards and forwards, Jaz, of the body being successful, and it is a balance, the body being successful versus the body’s starting to reject the implant, and this is why implant rejection can happen many, many years down the line. So if the patient gets sick, if they get put on certain medications, all of a sudden this implant that you’ve had success with for 15, 20 years, it may start to give you problems and fall out within the space of six months. So gone are the days where we think about an implant as being fused to the bone and kind of like, that’s it. There is a constant backwards and forwards, the bone remodeling around the area constantly. [Jaz]Dynamic situation, right? [Pav]Completely dynamic situation. So what we can do is we can split up this lack of integration. And to clarify integration of an implant is not just this. Again, let’s keep it simple. It’s not just this fusion to the bone Jaz. It’s the absence of any types of inflammation, disease, and it’s the ability for the implant to bear load as well. Because if the implant can’t bear load, what use is it? So the definition is multifactorial. Now, there’s a number of points at which we can have failure. And one of the failures is early stage, which is from when the implant goes in to when you take compressions. And sometimes we get patients coming back and they come back because they’ve called after two weeks and they’re like, ‘Pav, I’ve got a lot of pain. It feels really weird.’ And all this, but there’s a strange taste coming from it. And you look at the implant and you’re looking at it and you can just tell something’s not quite right. And at that point you need to make a decision. You’re going to take it out or you’re going to wait. And normally the best thing to do is take it out. So that’s kind of like the early stage failures before we’ve even managed to put a crown on the tooth. [Jaz]What I’m already thinking about, Pav, in terms of my restorative background is, resin bonded bridges, for example, we know that they could fail within the first four years, but if they make it to four years without any issues, they’re going to make it 10 plus years without an issue. So most failures, when they’re going to happen, are going to happen within four years. Do you have such stats for implants or your experience that you’ve learned that when you get implant failure? Because the way you suggested it is that even 20 years later, it could have a failure, which is a really obviously we know that they don’t last forever, but the type of failure may change. Any stats on if you get past this point, then you’re looking good? [Pav]Yeah, 12 months, 12 months after loading. And the reason for that is quite simple. If the bone metabolism is compromised, if the patient’s not quite as healthy, there’s the number of factors which come into play. It may be that at the time of impression that the implant’s absolutely fine and then you put a crown on it and you start to function on it and that may tip the balance that there’s too much force going through the implant into the bone and then the body decides, no, I can’t deal with this and just splits the implant out. I generally tend to find once we’re past that 12 month mark, at that point, we’re kind of into average territory. And there’s a number of factors we, I do a risk assessment, which tells me based upon these parameters, I’d expect a lifespan of the implant of 10, 15, 12, 15, 20 years, whatever it is, but that danger zone is really within the first within the first 12 months, because if you’ve made a technical error or your labs made a technical error is going to come to light really quite quickly. And so I generally say 12 months is kind of like the point after which I’m just like, ah, okay. [Jaz]Good. And then with my endo hat on, how an endo, they’ve got studies like survival versus success. And survival was like, well, the tooth is still there. Yes. There’s an apical infection, but the patients don’t choose on it. So it’s survival, but it’s not success. Is there such stuff about implants? Like you could have an implant with peri-implantitis it’s oozing, it’s pussing. A patient still chews on it, and it’s just slowly dying its death. Do you have such data like endo, like survival and success? [Pav]Yes, absolutely. So most of the statistics where people talk about success rate with implants, they actually referring to survival rates. And this is a clarification that a lot of dentists need. And then we need to define what success is, there’s a number of different parameters to it. There’s a mechanical success, there’s a biological success, and then there’s an aesthetic success. So all of these factors kind of like come into play, but most of the stats that you hear when people talk about success, they’re actually survival. So when people say, oh, implants have a success rate of 98% over a 10 year period, the caveat to that is actually that that’s normally a survival rate. The success rate is normally significantly lower around the 68% to 70% mark. Now, a lot of these problems are iatrogenic and they can be avoided, but in order to avoid them, we end up needing to do more complex treatments such as more complex bone grafting and soft tissue grafting. So this goes back to the osteoimmunology principle that I spoke about before Jaz, and the best way to think about it is the plaque, the bacteria, the biofilm, they cause an inflammatory wavefront. Okay. And it’s about two millimeters away from where the biofilm is. Now, what all of the evidence tells us is we need two millimeters of bone around an implant and two millimeters of soft tissue as well. And it’s not just any soft tissue, you need keratinized tissue. And what that does is when you have that, the survival and the success rate significantly goes up for the implants. So when people do that, that’s when you have true success rates of 98% over a 10 year period. Because what you’re doing is you’re keeping that inflammatory way front away from all of the sensitive area. And when you do that, all of the remodeling, all of the dangerous stuff happens at a remote distance. And this is why all of the studies suggest you need two millimeters of bone, you need two millimeters of keratinized tissue, because what it’s doing is, that then falls in line with the osteoimmunology principles, which we’re starting to employ nowadays. [Jaz]Okay. Well, if you’re a young dentist and you’re starting new or if you’re an established dentist and maybe you’re getting into implants or you don’t do implants, but this is something that’s quite fundamental to know, right? It’s like even though you don’t treat lots of perio, you should know about perio. Implants is obviously everywhere now. So we should appreciate how our colleagues can get better osseointegration. Some of it is actually factors that the GDP can help with while they’re on the way to see an implant dentist or, and their journey into implants. So what are some things that you employ in your protocols to boost that percentage? That at 12 months, everything and beyond, everything’s going to be hunky dory. [Pav]Oh, how much time have we got Jaz? This could be a very long podcast. [Jaz]Six minutes, no I’m joking. It’s got a bit longer, as long as it takes, but let’s cover some quick tips to help people out to maybe some of, oh, I didn’t appreciate that or, okay, that’s a really good point. [Pav]So my master’s thesis, cause my MClinDent is in implantology. My thesis was on ‘What’s called Biological Aging of Implant Surfaces’. And what happens is once implants are manufactured and they are sterilized and they are packaged, their bioreactivity, which is their ability to interact positively with the body, reduces very, very quickly. You can get a measurable drop within 24 hours. [Jaz]Wow. [Pav]And after four weeks, Jaz, the bioreactivity has reduced by 50%. Okay, so this bio reactivity is reduced by 50% and the bone to implant contact ratio that we’re getting of integrated implants and bone to implant contact, very simply it’s an indicator of how much bone is touching the implant and it’s an indicator of success. And a successful implant generally has a bone to implant contact ratio of 56%. So there’s only 56% bone around an implant and these implants are still lasting a long time. Now, what I found out is if you decarbonize an implant chair side, just before it goes into the patient’s mouth, that bone to implant contact ratio jumps to 98%. It’s a huge increase. So the discussions that I’ve had with colleague is yes, but is it clinically impactful? Because we’re still getting a very high success rate with this 56% bone to implant contact ratio. Well, the answer to that is really simple Jaz is what’s the other 44%. It is soft tissue, it’s biofilm, it’s all sorts of stuff. So we want to exclude that as much as what we possibly can. And in addition to that, when you decarbonize an implant before it goes in, it reduces the biofilms adhesion to the implant surface as well. There are also what are called finite element analysis studies, which show how much stress and strain go into certain systems. That they’ve shown that when you decarbonize an implant and you put it into place, the forces around the neck of the implant are significantly reduced because you’ve got this tighter bone seal around. [Jaz]Now I’ve seen some videos Pav on Facebook. Is this the purple beaming light on the implant that you’re doing? Is that the decarbonizing because it literally looks like you’re in Wakanda and is vibranium implants is why I commented ones on your Facebook post. So that’s what you’re talking about I mean, is this a machine you got to buy or how does this work? [Pav]So there is a number of ways to do it. One of the first ways that came out was a UV-C chamber. The issue that we have with that, A) That chamber is incredibly expensive. B) It’s not available in Europe anymore. And C) The cycle is about 12 minutes long. So basically, if I want to decarbonize an implant, I take it, I put it in that chamber, and it takes 12 minutes for the implant to be spat out before I put it into place. And another way of doing it is to use an alkali solution. Now, alkali solutions are used by a company called Thommen, and their implants come pre packaged in this alkali solution. You press a little button, it surrounds the implant, give it a little bit of shake, count to 60 and place it. So some people, I know they purchase the alkali solution, they just use it like that way, but other people are, I don’t want to add anything to the surface of the implant, particularly something which is kind of like they’re just like, I’m not comfortable doing that. And this new plasma unit, which is the Actilink. It’s nice because it’s only a 60 second cycle. And that’s that really cool video that you saw. You put the implant into the chamber, you press it and it goes, activation starting, and then it does this whole, Emperor Palpatine zaps it with this electricity. And at the end it goes, activation finished. And the patient goes, what on earth was that? And so it’s nice because it works incredibly effectively and it’s only a 60 second cycle. Now, what I would say Jaz, on top of that, there are certain implant systems, which come prepackaged in a sodium chloride solution, because they’re trying to prevent this contamination as to happening on the surface. So there’s two things that I would say to that. Firstly, when I take these implants and I condition them just before they go into place, I still get a better result with them. And secondly, there is a link between implant surface corrosion and peri-implantitis long term. And all of the people that I’ve asked, I’ve asked some very high-profile people, ‘Does storing the implants in this salt solution increase corrosion of the implant surface?’ Nobody’s been able to tell me yes or no. So in my mind, it’s actually an untested system. It’s an untested surface, but not only that, is even if it were a tested surface, you still get a better result by chair side treatment just before the implant goes into place. And this is one of the most impactful things that I have done for my implants. I’m not worried about marginal bone loss. I generally don’t see that anymore. I’m getting vertical bone growing around it. And it’s not just the amount of bone that you get adhering to the surface, Jaz. The quality of the bone is significantly increased and the speed of integration is significantly increased as well. So it’s upregulated on every level. [Jaz]I mean, it makes sense. It’s one of those things where it just makes sense to do because like you said, what’s the other 44%? Are there any long-term clinical trials yet to support this? Or is this something that we’re waiting to see if it actually results in clinical differences? [Pav]So there are some clinical trials as with everything it started with animal trials and things like that. But we’ve known of this concept since about 2008. So it’s not a new concept. [Jaz]Okay. [Pav]As with everything it kind of takes a little bit of time to get the ball rolling with this. There are some good studies coming out now, which is what they’re showing and these are human studies taking what are called ISQ readings and ISQ reading, you use a little peg and it gives you a numerical number as to how much your implant has integrated. So it gives you a numerical value as opposed to us just guessing. So these new studies, what they’re showing is we can take these implants and put them into patients who are very medically compromised or whose bone is so poor that these implants are just spinning. There’s a term for it in implantology, we call them spinners. We’re always worried whether they’re going to integrate or not. And some of these, what we call ISQ readings, they’re so low to start with. That the ISQ is, it can’t even be measured because it’s so low. And then what we know is if we can achieve an ISQ of 70, again, it’s just a numerical value. We know at that point, the implant has integrated. And what we’ve shown is we’ve shown that these patients who have this extremely low ISQ get an ISQ of way above 70 within 12 weeks. And normally we wait six months for these patients. So we’re getting integration within 12 weeks. And then from the point of restoration, these patients would be followed up for two years, showing that you don’t get an increase and then a decrease again, you get this increase in bone quality and then it’s maintained as well. So there are some studies starting to come out now, and I’m confident that as time goes on, we’re just going to see more and more of this. [Jaz]Excellent. So the first tip there is decarbonizing. I’m just, all I can think about the whole time is this company that produces this, the unit they use, they need to make a Marvel Black Panther version. I would just love it. That if it just had the music going and then suddenly, like they said in Black Panther’s voice, like a vibranium completed, like, I would just love that. That’s mostly what I’m thinking about right now. [Pav]Maybe I should get like a bespoke one made just like that. For me, like all marvels. [Jaz]I’d buy one. I’d buy one. I didn’t do it, but I just buy one and I zapped my crowns with it. And I just wait for that. And I’m patient. Be like, wow, what’d you just do to my crown? Like decarbonising. There’s all sorts. We can do that. The world’s our oyster. Okay. So tip number one, that is a decarbonize. This is brand new to me. So decarbonize your implants. Thanks for sharing the science behind that. Another thing. [Pav]So another thing is drilling in the correct sequence and in the correct manner with the right tools based upon the patient’s local and systemic factors. Okay, let me explain that a little bit more detail. So there are four different qualities of bone that you get bone, which is really, really soft. And then you get bone, which is really, really hard. [Jaz]It’s like wood. [Pav]Yeah. Either one of those two extremes is not good. So when bone is very, very, very hard, it generally has a very poor blood supply. And when it’s very, very, very soft, it is generally not very metabolically active. [Jaz]That’s the spinners. Yeah? The soft ones are more likely to be spinners. [Pav]Those are the spinners. Yeah. These are the patients where you open a flap, you drill and it’s just yellow fat- [Jaz]Vanishes in there. [Pav]Yeah. It just vanishes. You put suction on it and all of a sudden it is, there’s no bone left. And you’re like, what am I supposed to do here? So we want something kind of like in the middle. And that’s the best bone to actually put it in. Now, one of the things that I always get into, let’s call them discussions about is there is something called initial torque value. Okay. Initial torque value is kind of like how tight that implant goes in on the day of surgery. Okay. Now, a lot of people incorrectly state that if you put your implant in at too high torque that it causes pressure necrosis of the bone. Now, there are some really good studies to show that this doesn’t happen, but I think it’s a little bit more nuance than that Jaz. Okay, so there’s two different types of bone. We have trabecular bone, which is the bleeding bone. It’s the soft bone in the middle, and then we have the hard cortical shell on the outside. So on that scale of very soft to very hard bone, we need to know what our bone type is so that we modify the shape of the recipient site called the osteotomy based upon that bone type. So what I’m saying to you is if I’ve got softer bone, I can under prepare and squeeze in that implant and achieve the same torque value as very, very dense bone where I over prepare. And I get the implant to drop in almost to the apex and then it’s the last two turns where I achieve all of my what’s called initial torque value. So the initial torque value on both of those may be the same. It may be 50 newton centimeters. But where and how we attain that 50 newton centimeters is very, very different. It could be 70 or 100 newton centimeters. So it’s not just simply a sequence of going through your implant drill kit because your drill kit’s really nice quite often it’s color coded and you get told use this one then this one then this one then this one. Unfortunately, it’s not as straightforward as that so you need to shape the osteotomy based upon the implant and the type of bone as well. [Jaz]Okay. [Pav]The other aspect to that as well is You don’t want to overheat the bone. If you overheat the bone, that’s when you do thermal damage, and that’s when you’re definitely going to have issues as well. I’m actually surprised at the number of people who don’t track how often they’re actually using their burs, because they should actually be replaced very, very frequently. And the denser the bone, the more work that bur is having to do, so the more frequently you need to replace it. [Jaz]And any guidelines? Some people might be doing this thinking, ‘Oh, I’ve never replaced my kit.’ What’s the life cycle of a drill kit? [Pav]Every 10 uses at the very most your burs should be changed, at the very most. And sometimes if I’ve got really, really, really dense bone, I will use the bur once and that’s it. I’ll get rid of it. I don’t want to take that risk. Just for the sake of saving a few pounds, a few dollars that all of a sudden that I’m going to increase my risk of problems, and lack of integration. Now, the other aspects of that as well, it’s really a nice biological drilling is we reduce the speed at which we’re actually drilling. So what we know is if we put the burs in at 150 RPM or less, without irrigation that we don’t get that much thermal damage. Now there are certain bur designs which are even more efficient than that. So I have a bird design which I use very frequently, use it pretty much all my things and I could run that at, so the cardinal rule is, you don’t want to drill more than a thousand RPM, 1200 RPM if you’re really feeling like an absolute madman. So with these burs, they’re so hyper efficient at how they work, I can run them at 2000 RPM without irrigation in the most dense bone and they still won’t generate heat. The downside to it is you don’t get much tactile feedback. So they’re only really for more experienced implant places, or if you’re using a guided system, then you can use it. But by reducing the amount of thermal damage again, we’re just accelerating the body’s ability to heal. And in addition to that, if you do get thermal damage, firstly, you’re going to have more pain. You have this zone of death around the implant, which the body has to clear first, and then it reattaches the implant to the surface. So having the correct osteotomy shape for your implant design in the correct bone and using the correct burs in the correct fashion and reducing thermal damage, it plays absolute wonders. [Jaz]So I love the zone of death that made me chuckle. And so the summary there is the right tools for the right job and respecting the bone in terms of making sure that it’s irrigated and preventing thermal damage. [Pav]Correct. [Jaz]Amazing. Shoot us with love. And you got to tell me roughly when you think, okay, we’ve covered the main things because this, as this episode is your baby in terms of your top tips for osteointegration. So we’ve covered two already. What else have you got? Because I think something more systemic and medical is coming soon as well, I think. [Pav]Yes, correct. So Just before we move on to the systemic stuff, I think we don’t disinfect the osteotomies as well as what we should. We just drill and then we just place. So there are good studies to show that if you have a big periapical lesion around a tooth and you take that tooth out, you degranulate it and you wait for it to heal, you come back in six months time, those bacteria that were present are still present. They’re not cleared in the bone, even though the bone appears to be healed. So then if you are preparing your osteotomy and putting your implants into this position, the bacteria are still there and they are linked to failure long term. So what we need to get in the habit of doing is disinfecting the osteotomy. So it’s a little bit too nuanced for this, but I would recommend that everybody should be disinfecting the osteotomy just before the implant goes in place. So the way that I do it is I know what implant I’m placing, I prepare the osteotomy, I start my disinfection process and I then put the implant into the decarbonization chamber and then it all starts to kind of like tie in together. [Jaz]Are you squirting some chlorhexidine or some ozone or like, what’s your chemical or mechanical? [Pav]No chlorhex, should not be using chlorhexidine when it comes to implants or surgery. So there is risk of anaphylaxis when it comes to chlorhexidine. It also reduces fibroblast development as well. So I don’t like, even when I was doing general dentistry Jaz, I didn’t like it. There was always something that I preferred. So my go to at the moment is Clinisept+ mouthwash, which is hypochlorous acid. It’s very, very mild. And then what I do is when I am disinfecting the socket, I will use either iodine or I will use a bluem gel or I’ll use a hypochlorous acid. It depends on what I’m trying to achieve, but there’s a number of ways of effectively doing that as well. Okay. [Jaz]Okay, great. So decarbonize, respect the bone in terms of thermal damage and correct sequence and disinfect the osteotomy, osteotomy being the hole that you make in the bone. [Pav]Yep, correct. So systemic factors. Now this is where it starts to get interesting. There are a whole host of factors which can interfere with your early stage healing but are also involved in this osteoimmunological balance in the long term as well. And what we need to look at is we need to look at generally how fit and healthy the patients are coming in. So there’s a number of things that I’m looking for. If a patient comes in and they are at increased metabolic syndrome risk, so their blood pressure is elevated, they are looking overweight, they don’t do much cardiovascular exercise, is what I know is the level of systemic inflammation within their body is significantly increased. If somebody is diabetic, they generally have low vitamin D as well. If somebody takes antidepressants, that can significantly impair how your implants are healing. If somebody’s got high cholesterol, then that can also impact with how your implants are going to heal as well. So, I think it becomes a little bit unreasonable that if somebody was to walk through the door, that you just turn around and say, well, hang on before we do anything for you that we’re going to, you know, check your vitamin D levels. We’re going to check your blood pressure. We’re going to check your HbA1c levels. We’re going to do this, check that, check, we’re going to check your cholesterol, because you’ll just turn patients right off. So my point being is that if a patient comes in and I’m doing more complex work, so if I’m doing full mouth, if I’m doing zygomatics, if I’m doing big sinus lifts or large bone grafting, things like that. I’m more likely to do these checks beforehand and the way that I say- [Jaz]It’s like a risk assessment. It’s like case by case- [Pav]Risk assessment, systemic risk assessment. If a patient’s coming in, I’m a little bit worried, but it’s a single tooth. It’s just kind of like, well, I may pitch it to the patient, but if they don’t go ahead with it, then I’m not overly insistent on it. Sometimes you get this odd patient where it come in and you put an implant in and it doesn’t take, you wait for it to heal. You put the implant in and it doesn’t take again. And you’re like, let me do a blood test. I’d say that 90% of the time. That blood test shows something undiagnosed, which has been impairing the healing for the patient. So we need to look at kind of like the general overall health profile of the patient and take it into balance with regards to what we’re doing as well. And the main thing- [Jaz]I think, Pav anything surgery, like, I think even perio, just general perio, looking after periophile patients, these are often diabetic patients. There’s a rise in getting clinicians to take a step back and look the patient as a whole and look at their medical history and try and promote better habits and vitamin D and get checked out to boost even your perio outcomes. So it goes hand in hand with we’re doing if implants, and I saw one of your social media posts maybe eight years ago about how many patients are low in vitamin D and how it’s important to check this. I think I remember Hatem Algraffee also posted about this as well in his perio patients. [Pav]Correct. [Jaz]So these are things for healing. It’s all about wound healing. [Pav]So in fact, all of these things link back to osteoimmunology. So vitamin D deficiency and diabetes are linked. And they are also linked to MetS risk, and they are also linked to osteoimmunology. So what we’re finding now is all of these random things, which is kind of like, wow, we didn’t understand that that would be linked. Actually, when you trace them back, they’re all kind of like falling underneath this umbrella of osteoimmunology. This is why over the next, I’d say, five to 10 years. The paradigm shift is going to be more towards the osteoimmunology way of thinking as opposed to just pure biomechanics. And it’s the right way to approach things because it helps us treat and plan for the future and it helps us understand the risks of what’s potentially going on now as well. [Jaz]So, these protocols are essentially what you, I see you talking about it, super Superosseointegration. I love the term. Everything’s sort of like superhero base, Marvel base. I like it at zone of death, et cetera. I just, these are cool terms for me. So I love what you post about Superosseointegration. Obviously, we’ve just crashed the surface. You’ve got a two-day summit coming up about it. Please tell us more about how you’re talking about Superosseointegration. What kind of format is it going to be this event? [Pav]So it’s going to be a live two day event in the middle of September. It’s 15th and 16th of September and day one. [Jaz]2023 in case you’re listening next year, 2023. [Pav]And it’s going to be what we’ve discussed in a lot more depth. So we’re going to be going into depth about osteoimmunology, how we do things, why we do things, decarbonization of implants, I’ll show full disinfection protocols, osteotomy protocols. So we’re going to basically flesh all of this out that we’re talking about. Day two is a full arch treatment planning masterclass with a heavy emphasis on pterygoid implants. We’re going to tie in the osteoimmunology and all of what we discussed on day one into the full arch treatment planning masterclass and we’re going to have like a round table as well where we’re all going to kind of like brainstorm. So if anybody has cases that they want to discuss bringing together that they’ll get to look at it kind of like as a group, I think it will be a good exercise for everybody. So that’s the- [Jaz]That sounds very engaging and group work. I love that way going. But is this like, is it a two day package or can someone who’s not doing pterygoid implants come to day one only like, who is the ideal person at what stage of the implant journey should they be coming to learn about Superosseointegration and your day two kind of thing. [Pav]So it’s not an independent package for each day. This is going to be best suited for those people who are placing implants and who are kind of like early on in their full arch career or are about to get into full arches and things along those lines. Even if they’re not doing full arch, they’re still going to get a lot from the diagnostic aspects of it and from the Superosseointegration that we’re and the biological principles that we’re going to do on day one. It’s going to be really, really interesting because I’m going to take a lot of dogmatic paradigms and just throw them out the window Jaz and what’s the best way to describe it? I’ll take my fingers and put them into people’s heads mix their thoughts around a little bit. Yeah, that’s the way that we’re going to do it [Jaz]Well, the other good thing about events like these is the networking, right? Implant dentists meeting other implant dentists around the country now, around the world who will be able to lean on for support set up, exchange WhatsApp numbers, keep in touch. It’s a great opportunity to meet like-minded people, maybe already doing full launches as well, or earlier on in the journey. So it’s a good opportunity I think, even if it’s just some, if it’s a course that you’ve already done before, but it’s the ability to learn further from your protocols and also to just network. Networking is so, so important what we do and mentorship. So it’s always something to be gained there. I think. [Pav]Yeah. Absolutely agree with everything you said there, Jaz. [Jaz]Amazing. What’s the website so people can just log in? I’ll put it in the show notes, obviously, but please just let us know the website so that people can book on. [Pav]So you can go to academyofimplantexcellence.com, reach out through there. Or if you go to Instagram and look for Dr. Pav Khaira, message me from there as well. And I’m pretty swift at responding to messages. So, because a lot of my time is now focused on the academy and mentoring. So yeah, I’ve got plenty of time to respond to messages. [Jaz]What I’ll do as well is, protrusive.co.uk/AIE. Academy of Implant Excellence. So /AIE, it will take you straight to that event page. So when you share the event page with me, I’ll stick it on there. In case anyone didn’t get it, it will be a /AIE. And then that’ll just take you to the page. Cause I love to support you, get your people to network and mentored and do all the lovely things that you’re doing. So Prav, thanks so much for giving me time to talk about Superosseointegration, four ways that we can boost our osseointegration. [Pav]Thank you, Jaz. Jaz’s Outro:Well, there we have it, guys. Thank you so much for listening all the way to the end, as always. Whether you are chopping onions or on your commute, I hope you found that useful. If you’re new to Implant Journey, amazing. Pav’s a great guy to learn from. If you’re more advanced, and I’m hoping some of those tips are going to be applicable to you to really elevate and raise your game, sometimes the whole systemic factors of patient, it can get neglected a bit. So this is a great thing, even in the world of periodontology, as we discussed. After recording a few episodes with Pav, I really get an idea that implants, like many other things in life, are all to do with marginal gains, right? Getting those one or two percent things correct, and overall, they add up to get you a good result. So it’s really paying attention to detail, so if you want to learn from Pav, please do go on the website /AIE, that’s Academy of Implant Excellence, and that’ll take you to the event. And of course, if you want a quick win and you want to answer a few questions to get CPD for this episode, so half an hour’s worth of CPD for this episode, just head to protrusive.app. That’ll take you to the web app and then all my episodes there, all my premium content’s there. We’re doing live webinars every month now. I think the next topic is about vertipreps, so watch out for that one. And if you are going to sign up to Protrusive Premium, whether it’s CPD you want, because you’re already listening to the podcast or for the premium clinical videos, my request is that you sign up via protrusive.app and not via iOS and Android, ideally, because Apple and Android, they actually take a really huge percentage. So if you want to support the podcast, you go on protrusive.app, make your login. And the cool thing is, once you download the app from iOS and Android, the same login that you made on the web app. That’s protrusive.app website. You can then use on Android and iOS basically. So that will, you get all the premium features without anything going to Apple, Android and supporting the podcast the most. So thank you so much for the hundreds of you who support the podcast so that I can continue to do what I’m doing. I’m always happy in the comments below. If you’re watching on YouTube, or if you hit me up on Instagram @protrusivedental to have your recommendations, what would you as a Protruserati like next on the podcast? I’m all ears always. Thank you so much. Once again, I’ll catch you in the next episode.

When and why should you use post crowns in contemporary Dentistry? Surely they are a thing of the past? Dr. Dominic Hassall, a restorative consultant, shares valuable insights on restorability and the essential concept of ferrule. He highlights the significance of restorability and the role of fibre posts in dental procedures, emphasising the ferrule effect in crown and onlay preparations. The ferrule effect ensures predictable outcomes by transmitting occlusal forces through the natural tooth structure, reducing the risk of failure. https://youtu.be/zQNReIIJCG8 Watch PDP154 on Youtube Protrusive Dental Pearl: How to Bone Sound for Ovate Pontics –Imagine you have a missing upper lateral incisor, and you want to use an ovate pontic for an aesthetic bridge. To achieve the ideal emergence profile, Jaz demonstrates how to assess gingival thickness using ‘bone sounding’ using a periodontal probe (please see video). This technique helps determine how thick the tissues are overlying the edentulous area and whether an ovate pontic is feasible (or perhaps a connective tissue graft is necessary). Throughout the episode, Dr. Hassall’s expertise shines through, making it a must-listen for dental professionals seeking a comprehensive understanding of restorability and ferrule in restorative dentistry. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode:0:25 – Introduction to Dr. Dominic Hassall1:27 – Bone Sounding Clinical Video6:25 – Dr. Hassall’s journey into restorative dentistry9:04 – Function of Post Crowns13:35 – Composite for Nayyar cores18:10 – Assessing restorability23:25 – Impact of ferrule position on treatment outcome30:30 – Advantages and disadvantages of post techniques38:55 – Post Crowns as Bridge Abutments?43:08 – Dr. Hassall’s teaching institute details Dr Hassall gave a discount for his Diploma Course, head over to https://dominic-hassall-training.co.uk/contemporary-restorative-aesthetic-dentistry-online-blended-course-advanced/ and use the code “JAZ10” Jaz has no financial interest in this product. If you enjoyed this episode, check How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique Click below for full episode transcript: Jaz's Introduction: We are using less and less post crowns now, but is there still a place for them? Now, recently I had Dr. Pasquale Venuti on the show and he had some interesting opinions. He was quite a big advocate of the cast metal post crown in certain scenarios, where today's guest, actually Dr. Dominic Hassall, is well known restorative consultant, has a teaching institute, is a well-established educator, and he's very anti cast post crowns. [Jaz]He’s very pro COMPOSITE FIBER POSTS. So you’ll find out today what his views are on that. But we take a big, broader view of all things to do with posts in terms of when we should be placing a post. What about restorability in general? If you’re thinking about placing a post, then you are also debating, ‘Hmm, is this tooth even savable in the first place?’ We also cover the very foundational concept of the ferrule, which is so, so important when you’re considering if you can rescue a tooth or not. And also in terms of the long term outcomes for post crowns in general. Lastly, if you stick all the way to the end, we talk about this real world factor of communicating fees to your patient, because if your patient needs a root canal retreatment, and a post and a new crown, you’re kind of in the implant money territory, you know? So this is like a tough thing to help our patients decide which is the best scenario for their tooth. Hello, Protruserati, I’m Jaz Gulati and welcome back to another Protrusive Dental Podcast episode. Every episode I give you a Protrusive Dental Pearl. Today’s Protrusive Dental Pearl before you join the main episode is about bone sounding. So what is bone sounding? There’s a couple different scenarios we can use it, but let me give you a clear one because I’ve got recording of this that I want to show you on the screen. And a standalone video for this on YouTube just about bone sounding. So essentially, imagine you are missing an upper lateral incisor. You have your central, you have a canine, but you’re missing the lateral incisor. Now, if you want to do a bridge there and you want to use perhaps the canine and you want to cantilever, let’s say a resin bonded bridge, or maybe if it’s already a crown, you can do a conventional cantilever bridge. For example, and you want the pontic to look as natural as possible. Maybe this patient’s got a high smile line, right? So what you would want to do is choose an ovate pontic, like an egg shaped pontic that emerges from the gingiva and looks very natural. But to do that, we need to squish, we need to compress that gingiva, the gum overlying the edentulous lateral incisor area. Now, what you need to establish and find out is, how much wiggle room do you have? How squishy is this gum? If there’s lots of gum structure and you’re very lucky and you can squish it a long way, you can really get your technician to make a lovely ovate pontic and it can look extremely natural. But if it’s very thin amount of gingiva overlying the bone, then how can you possibly create a decent ovate pontic. You probably can’t, you probably need something like a connective tissue graft there. So this is where bone sounding comes into play. Now, what you do first is numb the patient up. You anesthetize the patient if you like them. Okay, now please, please, please anesthetize the patient. Anesthetize the patient and then you get your perioprobe. And what you want to do is you want to sink the perioprobe all the way into the gingiva. So when the patient’s numb and you’re actually penetrating the gingiva. All the way until you hit bone. Now, sometimes you feel some resistance and you think that’s bone, but actually that’s not bone. That’s probably connective tissue. It’s a bit tougher. You actually want to really go for it until you feel a hard bony block. So you can’t go any further. And then you measure how far into the gingiva are you before you got to the bone. So if you’ve got something like five millimeters, wow, happy days, right? You can actually make a nice three millimeter ovate pontic that sinks into the gums and emerges really beautifully and that’s amazing. But if you’ve only got two millimeters, one millimeter for example, then that’s no good, right? You know you need to think about some grafting or you can’t do a ovate pontic, you have to do another type of pontic like a ridgelap or something. So bone sounding is useful in decision making, it’s useful in treatment planning, and I just go into this a little bit deeper and I show you an example case in this standalone video that will be clearly on the app, also somewhere on YouTube which will be a lite version. Please do check it out if you want to learn more about bone sounding, but the importance of it hopefully I’ve explained to you, and now if you didn’t know this technique of bone sounding, now you know. Let’s join our main guest Dr. Dominic Hassall, and I’ll catch you in the outro. Dr. Dominic Hassal, welcome to the Protrusive Dental Podcast. How are you, my friend? [Dominic]Very well, thank you very much. Are you all right? [Jaz]Fantastic. Thanks for making time for this. I’ve just done the school drop off this morning and now I’m in the zone. You saw me put everything to do not disturb. And this is, I love obviously recording podcast stuff. It’s just an opportunity to switch off from the world and immerse myself and the Protruserati in some good quality education, which I know you are brilliant at delivering. I’ve seen so much of your stuff before as well. So just tell us a little bit about yourself as a clinician and as an educator. [Dominic]So really my background is kind of conventional NHS kind of consultant training pathway. So did the kind of full NHS consultant training pathway, worked part time as a restorative consultant for a while, but really wanted to set up my own training centre and really set up a centre where I could treat patients as well. One of the problems of being predominantly in the hospital is you don’t get to see many patients and you don’t get to do a lot of stuff. And I kind of like doing dentistry because I like doing dentistry, so it’s good to be in my own centre. Kind of doing my own thing really as a restorative specialist. The great thing with that then is because you’re doing a lot of it, you can pass on that knowledge through the training centre to other dentists as well, which is great and what I love doing. So the mix I have with the two is great, really. Love doing both things, really. [Jaz]Great. And things have changed in terms of training pathways that are available now, which one perhaps available when you were making that decision about which pathway you should follow. So you followed the STR training, restorative route, assumingly at the time that when you became a specialist you were on the register for all the specialties, is that how it worked? For restorative, for perio, endo, prostho? [Dominic]Yes, so you could sit the MRD. The membership in restorative dentistry and then nominate a specialty with that, but then when you came out with your full consultant training pathway and you passed all the exams for that you then became a restorative specialist but you could nominate another specialty as well that was of interest to you. [Jaz]Now, where I’m going with this question, Dr. Hassall, is if you were to do it now, if 2023 you’re applying for training, would you have gone down the same pathway? Would you perhaps have considered an MClinDent in prosthodontics, or would you have considered something different in terms of to get to the level that you are practicing at now? [Dominic]Very much depends what you want to do, but I think there’s much more options now. So, the institute here we run a sort of intermediate certificate, then an advanced certificate, then a diploma and an MSc, and there’s lots of other places do that. And I think if you want to stay predominantly within practice, I think that is a better career route now. Because it’s kind of, and with myself and other institutes doing the online blended, you don’t have to take as much time away from practice. The trouble with a lot of kind of traditional institutes is, yeah, they’re either full time, which just isn’t doable for a lot of dentists, or they are kind of significantly part time two or three days a week, which again isn’t doable. And if your ultimate gain, sort of aim is to kind of do what I would say high end private practice, I think you’re better off going down a kind of different training pathway really. And certainly with my institute, everything’s very practically based, very evidence based. So I think there’s a lot more options out there now than just the kind of traditional sort of training pathway and ClinDent. There’s, there’s much more flexible options now for dentists, which is great, I think. [Jaz]Agreed. And when I was at that crossroads and I was thinking, ah, should I go into specialist training? I really wanted at one point to be a restorative consultant, just like you, I want to be like that pathway. And then I did the hospital posts. And I fell out of love with hospital and to be able to go five more years in hospital. I just couldn’t see myself having a fulfillment from that. So I went up the private route and lots of the more contemporary courses that you have, like yourselves, for example, and that has given me so much training, education and experience to be able to practice at a level I’m happy with. Obviously, I still want to keep going, keep developing. I’m still a young dentist, but there are so many more options now than there were before. So you’re totally right on that. In terms of switching to the main topic today, which is Post Crowns. If we start with the very bare basics, we’re talking to dental students, let’s say, what is a post? Just start off with the general indications and how it comes into restorative dentistry. [Dominic]Really, I think the thing to think about with posts that the simple facts of the matter is the post is simply there to retain a call. That’s it’s only role. We’ve got to forget that, I mean, this has gone a long time ago, but there was all this kind of myth that posts reinforce teeth. Well, posts don’t reinforce teeth. Anything you do to the root canal that is removing what is left of that root dentine is weaking it. So the only thing your post is there to do is to retain a core. Now that can be a core for either a crown, or a bridge, more traditionally. Or it can be there to retain a core for a composite build up as well. So that is the only role of the post, is where you have very little coronal tooth tissue left. It’s simply there to retain that core. Nothing more, nothing less. And I think, if you get that sort of basic fact in your head, then you can’t go too far wrong. [Jaz]And when you were doing your restorative training, and compared to what you teach now, and what you practice now, tell us a little bit about if anything has changed in terms of either how much you’re using posts, or the types of posts you’re using, or the general philosophies and views on posts. [Dominic]Yeah, I think from when I did my undergraduate training, things have changed just dramatically. So, now don’t anybody go and do this, but when I was a dental student, we were taught to use paper clips as a temporary post crown. Now, obviously don’t do that anymore because the G-, that’s not going to go down well with your GDC or your defense union. But no, we were much more aggressive. I mean, some institutes would, we’re actually teaching for you to decoronate the tooth to put the post in. [Jaz]Wow. [Dominic]When I trained as well, we were doing quite technical procedures like split cast posts on molars. And that has all changed out of recognition. So I think the first thing that I would say these days is we just basically, we do far less post. So, with posterior teeth, what predominates over post now is the Nayyar core technique. Now, traditionally, the Nayyar core technique is basically opening up the access cavity, opening up the first two to three mms of the canal orifices, and then basically you used to pack amalgam in. Well, things have moved on from there because we now have bulk-fill, low-shrink, deep-cure composite. So you can actually do the Nayyar technique now with, with bulk-seal composite. So, you don’t really need to do posts on posterior teeth, and all the dangers that come with that, with trying to get the alignment right, trying to make sure you’re not perforating the canal. So, I haven’t done a post on a molar tooth in I would say decades. Premolar teeth I don’t think I’ve done a post on a premolar. [Jaz]Hey guys, it’s Jaz here interfering with a quick kind of testimonial or a positive comment that we received on Occlusion Basics and Beyond. So on our course platform occlusion.online, where we teach occlusion, Mahmoud and I, we ask for this bespoke thing whereby every lesson under every video lesson, we wanted to enable comments. So they didn’t have this before. So me and Mahmoud specifically requested it for this course that we want delegates to be able to comment under lessons. Now, we didn’t know how popular this would be, but we’ve been blown away about how many questions daily we get on the different lessons and discussions and debates. And it’s been absolutely brilliant. And what Craig shared with us on July 1st 7:17AM is on a video where Mahmoud discusses the envelope of function. He said, ‘this was so well explained. You have a gift for this. I too always try to create some positive overjet with orthodontics, but with what you said made me realize, after you have assessed a patient for braces, you could well completely encroach on this envelope when you consider a maxillary fixed retainer.’ So what Mahmood says that if you’re planning orthodontics, you’ve got to have enough overjet for the envelope function, but also consider about how a fixed retainer will impact this. Could your fixed retainer be encroaching your envelope function? So I want to put this in A) to raise awareness about occlusion.online. We’re super proud of it. We’d love for you to learn occlusion. If it’s something that you’re struggling with, let us make it tangible for you. And B) as a learning point, envelope a function. Have you got enough overjet? Have you got enough overjet? Once you factored in the position of the fix retainer as well. Let’s join again the main episode. Before we move away from molars and go to pre molars and anteriors, just because people might be wondering, as you said it, is there a bulk fill composite that you like, that you prefer, like a brand that you use that you like for these purposes? I think often Protruserati are like, ooh, I wonder what Dominic’s using. [Dominic]Yeah, I like the 3M, the bulk fill one. I like because it works well with the new kind of universal bonding system that 3M have. It’s a nice handling material. But the other thing I would say as well is what we’ve kind of pioneered at the Teaching Institute is heated composite as well. And heated composite works absolutely fantastic for core build ups. Because you can get it into the canal orifices. You can then start building up into the pulp chamber. Now you can only go to about 4, 5mm with that. So sometimes you’ve got to go 1, 2, for really heavily destroyed teeth, even 3. But yeah, that’s the material that I like to use. But don’t forget, pretty much every composite out there can be heated and used. You’ve just got to remember, it heated about 20 times, and that’s the limit that It’ll take, really, for heating. [Jaz]Are there any concerns about C factor, or is there any layering technique you recommend to minimize that if you’re doing, let’s say you’re building up a molar with a core with the composite dowels extending into the orifice, do you do it like the one sort of corner like a triangle’s or are you happy to connect walls with the modern composites? [Dominic]I think with the modern composites, particularly with the new 3M, because with the modern composites, they are much lower shrinkage than the older composites. In addition to that, basically you’ve got to have, because your composites absorb moisture, you’ve got to have a little bit of shrinkage in them for when they absorb the moisture. So the C factor worries me much, much less than it used to be. Because these materials are much lower shrinkage. They also with the cross linking within the 3M composites, they absorb the stresses better. With the heating and the modern bonding systems, you’ve also got a much better bond and adaptation to the tooth. So I think C factor, for those of us who have kind of gone to heated composite, worries us much, much less. The only time I would say that the C factor tends to come into play is, bizarrely enough, with the much smaller occlusal composites. That’s the only time the C factor kind of has more of a significant impact. But I think C factor with the modern composites is far less of an issue than it used to be. [Jaz]And if you follow the Bioclear protocols, they’re very happy to do that, the bond, and the flowable, and then the heated composite, and as they would also suggest that if you adapt your cavities correctly, then yes, C factor is much less of an issue with the modern composites. Now you’re moving to, so basically the theme here is molars, you haven’t done a post in decades, and nowadays with the Nayyar core technique with composite. We probably don’t need to talk any more about molars and posts in this episode. You’re going to move on to premolars. [Dominic]Yeah. Now premolars, you’re in that kind of transition zone now coming towards the front teeth. Is there still a role for posts in premolars? Yes, I’d say there is to some degree. Is there a role for posts in anterior teeth as well? Yes, there definitely is. Much less of a role, but if you have a tooth that just has no, virtually no coronal tooth structure, then you are literally forced into that decision as to, well, do, first of all, do I extract the tooth? Or, do I basically then, I wouldn’t say do something heroic, because it’s not heroic, it’s just, it’s going to have a shorter lifespan and it’s going to be less predictable. Doesn’t mean you can’t do it, but yes, I think that really there is still a role for posts. Definitely. Yeah. [Jaz]I think it’s all about restorability assessment and I think there are sometimes you look at a tooth and you think okay this one’s for the bin and that’s fairly clear cut and then on the other side this tooth is restorable with a Class IV composite. We don’t even need to do an endo and it’s extremely restorable. And so when we get to the middle ground, the gray area is that, ooh, is this restorable? Is this not? Shall I use a post? Shall I not? So if we talk about those two things in terms of just quick and dirty guidelines for the dentist, in terms of at what point would you consider, okay, there is enough ferrule here, if you can expand on the ferule, obviously a big part of today’s discussion. At what point is there enough ferrule to think, okay, let’s add a post on to retain the core and continue, versus, okay, at this point, the patient will be better served with an implant or something. [Dominic]Yeah, what I teach to, this is a study they use in America a lot, the undergraduate clinics. There’s an article by Samet and Jotkowitz, and it’s fantastic. It classifies teeth as A, B, C, D, and F with very good guidelines are what is the prognosis for that tooth. So I teach that a lot within my courses, that article. And basically what you’re looking at with the post, first of all, you’ve got to be able to get a decent root filling in it. Okay, so you’ve got to be able to get a decent root filling in it. And then it is all down to how much coronal tooth structure that you’ve got. Now, the one thing we know about posts is the importance of the ferrule effect. Now, the ferrule effect essentially means that when you’re going to prep the tooth often for a crown or an onlay, that you can get onto sound tooth tissue. The benefit of that is that when the tooth absorbs occlusal forces, those occlusal forces then go down into the tooth. They are less concentrated in the core, the post, or the interface. And it’s interesting, there are studies on the ferrule going back decades which show how important it is. Even up to recent times, there’s quite a recent article by Pascal Magne. And that actually looked at the ferrule being the most important thing in terms of post success. And we haven’t even got on to post materials yet. So the ferrule is absolutely crucial. Now don’t forget, if we can’t get a ferrule, we still have at our disposal surgical crown lengthening. We also have the use of lasers and electrosurge as well. So sometimes you can borrow a little bit of gingivitis- [Jaz]Orthodontic extrusion as well? [Dominic]Orthodontic extrusion, yeah. Do you know what? It tends to be less popular with patients, but certainly where that is very useful is where I’ve used it a lot in the past is with trauma cases. So you’ve had youngsters who’ve had trauma. They also need orthodontics as well as part of a malocclusion and then you can do the two together. And certainly, yeah, that’s something I’ve used a lot in the past, is extrusion of the tooth. But don’t, that’s one of the things is how much of a ferrule can I get? Then if you can’t get a ferrule, the prognosis for the tooth is looking far, far poorer. The other things with treatment planning that I think it’s worth mentioning now is you’ve also got to look at the occlusion. And when you’re doing that post core and that post crown, you really want to start treating it more like an implant and be trying to get a protected occlusion on it. So you want to be taking that final restoration out of the occlusion as much as you can. So very low slack cuspal inclines. And the prognosis is going to be obviously worse if they are patients who are bruxist. If you can’t take the tooth sort of out of the occlusion almost. Then the prognosis is going to be worse if you see what I mean. [Jaz]That makes total sense, by the way, in terms of the first time I saw this was in North East, I was in, dental school in Sheffield, prosthodontist, and I was reviewing one of his patients and there was a canine which he did a post core crown. It looked lovely. But it was slightly buccally positioned. It looked very natural. It looked like slightly crowded. And I had a look. I wonder why he’s done that. And I spoke to him. He said, ‘Oh, it’s because it’s a very compromised tooth.’ We want to treat it like it is just like you said, like an implant, which is like a novel thing to me at the time. So that was an interesting use of that. Now, before we move to the next points, one, just touch back on the ferrule, how important is it in your opinion? Cause we don’t know that the full facts on this in terms to have ferrule a hundred percent all the way around, or is there a minimal percentage like, okay, I’ve got good feral, 70%, this will be enough, any guidelines on that? And then exactly how much vertical ferrule is ideal for you? Obviously the more the merrier, but the papers say 1. 5 to 2 millimeters. Is that what you teach and what you follow? [Dominic]Yeah, the papers very much are 1.5 to 2. So I would still go with that. I would say, yeah, ideally you want to have the ferrule all the way around. Is that always achievable? No. Okay? The other balance is, yes, could I surgically crown lengthen it, could I laser it, or electrosurge it? But then don’t forget if you’re going to do that, the patient is going to accept at some point that the tooth is going to be slightly longer. Now that maybe is, that’s obviously more of an issue in the aesthetic zone. So if they’re happy to accept a slightly longer tooth, I would go for a longer tooth to achieve the ferrule. But I think that’s very important. Also, if you’re going to be just lasering or electrosurge, which is always a whole kind of just topic in itself, you’ve got to- [Jaz]I’m so sorry, Dominic, because it’s really important for the students listening to this, just to make clear for them, by longer tooth you mean at the gingival level, so, it’s going to be a higher gum line. [Dominic]Yeah, you’re going to have a higher gum line which for say if the smile line is low and the patient is happy with that and you consented them it’s not a problem. But say it’s an upper central incisor with a high smile line then that potentially isn’t going to be a starter for them really. They’re not going to go for that. [Jaz]And what about the position of the ferrule? So you know I’ve heard some people say that if you’re missing mesial and distal ferrule and maybe it’s half a mil, but you’ve got three or four mils of palatal ferrule, we’re talking about an upper incisor, that is actually looked on more favorably. Would you agree with that sort of mindset? [Dominic]Definitely. Yeah. I think really with the way it’s going to absorb the forces. I think, yeah, you can accept if there is a little bit of mesial or distal ferrule missing, but realistically, yeah, you want to have a full palatal and a full buccal ferrule, definitely. So, ferrule predominates, okay? Yeah, and I think that’s very much, have a discussion with the patient, because I treat all sorts of patients. Some patients, that would be the end of the world for them, that aesthetic compromise. But, if our patient is more kind of functionally driven, then that is less of an issue for them and they’re happy to accept that. [Jaz]So that’s restorability is very much hinges on the ferrule availability. And so you want as much as you can. But in terms of that decision, that tipping point of a post, any guidelines on that? Sometimes endodontist, they’re faced with a scenario where they’ve just finished the root canal and they’re looking at that tooth structure and they’re just about to put their core on and they’re thinking, should I stick a fiber post in at this point? Because we know that endodontist generally are very much against cast post and we’ll come onto that shortly compared to some other dentists. But yeah, where they’re deciding shall I put a post in any guidelines that you could suggest to an endodontist, a young endodontist in terms of stick a post in this scenario, but perhaps you don’t need it in this other scenario. Any guidelines on that? [Dominic]It’s tricky. What I tend to do with the course is we have a number of photos of teeth with different amount of, or different lack of coronal structure, and then kind of decide when you would need the post, if you see what I mean. But yeah, I would say much more these days, we’re kind of going much more for the heated composite and the direct Nayyar. I mean, if the tooth is virtually completely decoronated, but you can get a slight ferrule all the way round. Then I think you’re going to have to go for more of a kind of traditional post, if you see what I mean. [Jaz]By cast post? You mean, by traditional you mean cast post, yeah? [Dominic]Oh, no. I’ll come on to that in a bit. What I would say is a kind of, an indirect post, basically. [Jaz]Okay. [Dominic]Yeah. Post materials, I’ll come on to in a second. The more buccal and the more lingual wall there is the less likely I am to go for what I would say an indirect post rather than a direct heated composite post. [Jaz]Okay, brilliant. Well, this leads nicely into post materials So let’s say you find a situation where you have a doubt that if you do not place a post here you worry about what is retaining the core and you’re relying too much on the adhesion at that point, and the quality of tooth structure may not be so brilliant. So if you add post in that scenario, it could help to aid you in retaining that core so you can then proceed to placing a crown there. So in terms of materials, what are your thoughts? Probably changed a lot over the decades in terms of what you were taught because you’ve got lots more new materials as well. What are the sort of decision making in materials that you employ? [Dominic]Now, the other thing I would say is, again, I would not have done what would be termed a more traditional cast post in probably 20 years as well. So all the posts I do are composite fiber posts. The brand I use, because it served me well and the drill kit is quite straightforward, is the ParaPost. So it’s a composite post that they do. There’s lots of other brands out there, but that’s the one I use. And I think the next reason is why go composite fiber post? Because I think the thing with posts, the first thing you’ve got to tell the patient, this is kind of last chance saloon. So when we do this post, you’ve really got to be thinking about in a number of years, where is this tooth heading? Which is going to be extraction, and then it’s going to be either a gap, an implant a denture or a bridge. Why go with the composite fiber post? There’s a number of advantages to them over cast metal posts. Now don’t forget with cast metal it can either be just a cast base metal or it can be a cast gold post. So if you’re going to go cast post I would always go cast gold post rather than cast metal. The aesthetics are better with it, there’s less corrosion issues with it. But, essentially, I would go composite fiber. They are a different concept to a cast post, because the modulus of elasticity, or the stiffness of the post, is similar to the dentine. So it will actually move with the tooth slightly. Now, what are the advantages of it? Well, number one, if you’re going to go for a composite over the top of it, or basically an all ceramic crown over the top of it, you have no cosmetic issues, because you’re not trying to hide the dark grey post underneath. The other fact with them that I like, because as a restorative specialist, all of us are heavily involved in implants as well, the mode of failure of a composite fibre post is better. Now, when you look at the studies, generally how they fail is they fracture at gum level. The other mode of failure, which I don’t see a lot, is that they actually fully de-bond. Now, the good thing about that is when it fails and it fractures at gum level, you can show the patient, this tooth is now unrestorable, you make them a little partial denture, just a little flipper partial denture, and then they can think about their options. The mode of failure with cast posts is really troublesome, because what tends to happen with cast posts is they fail, but they’ve split the root. Patient comes in, you’ve got a quick emergency review. You’re like, oh crikey, what are we going to do? They’re going on holiday. You wash it, you clean it, you particle-abrade it all, and you recement it. The trouble is, in the meantime, there is a crack in the root, you’ve now got bacterial ingress into the bone, and you start losing the bone. And I’ve seen instances where people have kind of nursed along failing posts for six months, twelve months, two or three years. They then decide, right, I’m going to have an implant now. The implant is a lot more troublesome, because they have no buccal plate. And so they just don’t have the bone for simple implant placement. So the mode of failure with cast posts is much poorer. So I would rather go for a composite fiber post. Does it take less force to break them? Yes, it does. But then when they break, the mode of failure is much, much better, much, much better. [Jaz]You mentioned earlier about indirect posts that you would use though, right? [Dominic]Oh, yeah. The composite fiber post would be the only one I would use, to be honest now. [Jaz]Okay. In my mind, that’s like a direct technique. I mean, indirect being lab work. [Dominic]Oh, yeah. Indirect with an impression. No, I wouldn’t do that at all anymore. [Jaz]Okay. Got it. Got it. [Dominic]I haven’t done it for ages and ages. [Jaz]Got it, got it. And then what I touched on earlier for those listening about endodontists, why endodontists worry is because if you’re going to go for a impression and a class technique and an indirect flow with a lab, then you have to put a temporary post and what the endodontists think is that temporary posts are the devil’s work when it comes to micro leakage. You’ve just done a beautiful root canal and now there’s leakage and that’s always been my concern as well. [Dominic]Yeah. And I think the other thing with the composite fibre posts, what the studies show as well, Is they don’t need to be that wide, because certainly when I was at dental school you were taught to keep widening the canal to get the biggest post in. No, you want to go for a relatively narrow post. And with all the current bonding technology we have, it doesn’t need to be extremely long either. Okay, because we were taught to widen out the canals. No, you can go for a fairly narrow post. So once you’ve got rid of the gutter percha, and once you are onto the root dentine, you can pretty much stop. And then lengthwise, as long as you are going realistically, you’ve obviously got to go below the bone crest into the root. As long as you are doing that, you don’t have to have posts that are 13 millimeters long anymore. Because the risk of perforation is too great with those. [Jaz]That’s true. And just to make clear to any dental students, the reason why you want to go beyond the bone is? [Dominic]Basically, you’ve got that bracing effect. And you see with implants as well, sometimes implants that lose bone the top of the actual implant itself can break because it hasn’t got that bracing effect from the bone. So you really want to get below that level there. Yeah, definitely. [Jaz]Have you seen or used some of the new posts? I haven’t used them myself yet, but the actual fibers that they place and they sort of are building up the posts as they go along by using sort of pieces, strings of fiber, if you like. And then they’re making this, I see the benefits because you’re essentially using a fiber and then you can adapt to the shape of perhaps an oval shaped canal. Have you used that yet? Have you seen it often? [Dominic] I haven’t used them as yet, but I have seen them. Where I think they have a role is when you have an endodontically treated molar. But you’ve been quite clever, so you haven’t gone for straight line access down the canal, so you have a lot more coronal tissue. And I think those sort of, what I have seen the endodontists doing, is kind of mixing those fibers with composite. rather than going for cuspal coverage on the tooth, essentially. But if you’re going to use those endodontic techniques, you kind of need to know exactly what you’re doing with it. They’re not the easiest to master. [Jaz]Sure. So to summarize, your philosophy on posts is composite fiber posts. When you need one, then that’s what you’d go for. We don’t need to certainly we don’t want to prepare the canal any more than necessary because that’s going to weaken the tooth and that’s definitely something I was taught as well at dental school. Pascal Magne, he’s quite a biometric group. They’re quite anti posts. I think you are as well, in a way, you don’t want to have to use them unless you really have to. What do you think about that? [Dominic]You see, because I’m a restorative specialist and I do everything, I just kind of look at the bigger picture. Pascal Magne he’s very implant led, if you see what I mean. The trouble with some patients is, first of all, there might be contraindications to implants. They might be diabetic. They might have periodontal disease. They might have this, they might not be in the best health for implants. So if there’s any contraindications to implants, that’s going to affect my decision to try and retain the tooth for longer, essentially. Also, I think the one that we haven’t touched on as well is, is the cost of it as well. [Jaz]I was just going to come to that. In the real world conversations, because these are the, if you’re factoring in potential a re-RCT, a post, a new crown, and then you’re not too far off in implant territory, this is where it becomes a financial equation. I’d love to hear what you think about that, also how you communicate that to patients. Ultimately the patient decides, but we need to lead and guide them as well. [Dominic]Yeah, I think that’s the other thing, that when you start adding up the cost of saving the tooth, you want it to have a pretty good predictability. [Jaz]That’s it. [Dominic]Sometimes it’s very patient led because you have these patients who basically write, yeah, I’ll do anything to save the tooth. So those are easier to treat because, right, yes, we’ll try and save it. You then have the patients who are very much, well, what do you think? What do you think the best option would be? And sometimes you’ll be like, look, you’re a smoker. You’ve got periodontal disease, you’ve got and I see this on a weekly basis, you’re diabetic as well. I don’t think implants are the best thing for you, okay? I think trying to save the tooth is going to be the very best thing for you, because you’re not a great candidate for implants. Whereas with other patients, you look at them and they have immaculate oral hygiene, they have no medical considerations, and then when you start weighing up the costs of it, you’re leaning more towards extraction and implant placement often with those patients. But I think the other thing with the sort of Pascal Magne, it’s kind of what we’ve experienced with post crowns, and it’s the mode of failure of cast posts. That they come and see you as an implantologist and you’re basically right. I’ll take the tooth out, I’ll clean it all up, but then you’re going to have no bone left. And then you’ve got this whole other issue of what are we going to graft it with? Are we going to graft it with an autogenous bone? Are we going to use a bone substitute? And all the aesthetic considerations that come with that as well. So it’s tricky. But yeah, I’m definitely not anti post. I’m anti cast post. But I think, yeah, I think the cost is saying you’ve really got to factor in as well. [Jaz]I’m going to make up a pretend scenario. Just, this is a play with me here. Patient, 34 years old, male. Has an upper left central, which has a shoddy root canal, and now it’s fractured. You’ve got two millimeters of ferrule to play with, 360 degrees. If you treat him, obviously you’ll need a re-RCT, post and a crown. But we can also go for, let’s take it out and go for an implant. He’s otherwise medically fit and well. Are you trying to save the tooth for this gentleman, or, are you suggesting implants as the first choice? [Dominic]I would sort of say 50 50. I would say, if he was 20 years young older. Yeah, it’s how long the post is going to last because posts, there’s lots of studies showing on average how long posts last, but when you do a post, it’s going to have a compromised lifespan. So certainly with an older patient, you’ll be thinking actually this might see you through if you see what I mean. This may be your final restoration. The younger patient, you may be better off doing the post because then you can delay the implant for 10, 15 years if you see what I mean. And there’s no doubt with implants that technology moves on all the time if you see what I mean. So, with a patient like that, I would be to some degree more inclined to try and save the tooth. But it also depends what is happening around it as well. [Jaz]The occlusion, the aesthetics, the gingiva. It’s a very open question, but it’s, without showing you a specific case, but, I think you touch really well on occlusal, the periodontal factors, aesthetic factors, low lip line, high lip line. We covered a lot there. Any final points for those Protruserati listening about posts in general that you’d like to add in there? [Dominic]I’m just trying to think. I think we have pretty much covered everything, but yeah, I would kind of shed away, I think, the kind of anti post kind of movement with some endodontists, I think that’s justified to some degree because of old cast posts, but certainly with composite fiber posts, I think when they fail, no, you’re still fine for the implant, which is great. So I don’t think that, I don’t think they compromise the implant site as they used to because when mine fail, you know, and I’ve been doing them for 20 odd years, so I have had them fail, they tend to be fracturing at gum level. Or, very rarely, they just completely de-bond, but it’s virtually unheard of that they actually kind of split the root and you can stick them back in. So I think in that respect, I think it’s just looking at it and thinking, well, what do you think is going to be the best thing for that patient? The final thing I would say about it as well is because also, the one that we didn’t touch on was using posts as bridge abutments, because that’s the other thing. And certainly what the studies tend to show is that if you can get a ferrule and control the occlusion, that basically a post is a reasonable support for a short span bridge. So basically three units. But where they start to obviously just break down these longer span bridges. So that’s a question I get asked a lot is, Ooh, I’ve got this post crown three. Can I use that as a bridge support to a six? And I’m very much, no, basically. That’s a poor prognosis. [Jaz]Let me throw a curveball in there. What about a cantilever off a post, crown tooth? [Dominic]Definitely not. Cantilevers tend to be bad news, full stop. But yeah, you’ll see them occasionally. You’ll have a patient walk in, you take some x rays of them as a new patient, and they will have a cantilever, a cantilever bridge off a post crown. And they do well, but statistically, posts don’t do well as cantilevers and cantilevers don’t do as well anyway. [Jaz]Yeah, I’m not as brave now I mean if I’m going to be doing a cantilever It’s either going to be a resin bonded bridge with lots of enamel or it’s going to be a decent perhaps it’s an old crown that we’re taking off and you see lovely to structure inside that’s probably going to be a scenario where I would but otherwise I totally agree. I can’t risk doing a cantilever off a post crown tooth, but it’s good you mentioned that. It’s perhaps a short span bridge. It can still be a consideration. I’m very glad you mentioned that. Dominic, where can we learn more in terms of, because you said you do a blended program. So it’s online and in person. Tell us more about where we can learn more from you. [Dominic]Yeah. So I have the training institute in Solihull. Which is great, because we’re close to the train station at International Solihull, we’re close to the airport. And yeah, we run our courses in two ways. A number of years ago, we kind of moved away from just the traditional method, where people come once a month, or kind of once every two weeks to do the course. And what we found was, we basically do sort of high quality, regular recordings of all the material. And so what people can do is they can effectively do half the course online. Now the beauty of that is you can do it when it suits you, on a device that suits you. You don’t need to take time away from clinical practice. And then you can come and do that hands on component in a kind of five day block. And we do that very much for our Level 1 course. And we do it for our Level 2 course as well. You can still do it in the traditional method if you want to come more often. But we find that the blended format has become hugely popular. And what I like about the blended format as well, if you’re not quite getting something, you can hit the pause button, you can rewind it, and you can watch it again. And then if people really aren’t getting it, we do an online forum, so they can just basically email you in and get the answer that they need. And we did that, we kind of did that, oh, many years ago, about eight years ago now. And obviously COVID has kind of accelerated that kind of teaching now. So, it was popular before COVID, but it’s got even more popular now as well. [Jaz]What I like about that is the maximizing the hands on. When you’re coming, you’re taking time off from work. You’re not just sitting, listening to lectures, which you could have done online at home. You’re really maximizing the hands on. Is that the kind of way you do it? [Dominic]Yeah, we find people are just better because they’re better prepared. You can come in to do the practical, you do a short little recap, and then they’re straight into the practical. And then you can have, just a really enjoyable time with people just getting on with what is the job of dentistry, which is the kind of, we can do practical exercises in diagnostic and then all the composite exercises. Or the inlay, onlay, resin bridges, conventional bridges as well. So we can do all of that. Oh, and there was one thing yes, that, where people can come for all this information, if they go to dhti.co.uk, so if they hunt us down on dhti.co.uk, we have all the courses on there. But what we also have is we have what’s called the evidence-based toolkit. So what we have is a kind of wealth of all our materials on there. Which I like because people can kind of get free CPD on there. But what is nice is that they can kind of see like is the courses that we’re offering the kind of course that they want to do if you see what I mean. Do they like the style? Do they like what we’re doing? And I think we have got running if i’m right, I think we’ve got a 10% discount or a discount on the courses at the moment. So if they use the discount code Jaz10, they can get a discount. [Jaz]Wow. My guys love a discount code. So Jaz did all, all about Jaz10. [Dominic] But yeah, if they head to the website, they can have a good look at the evidence space toolkit, pick out some of the things that they want to have a look. We’ve got practical videos, lecture videos. We’ve got some of my articles on there. So there’s a whole wealth of stuff that they can have a good look at on there. [Jaz]Now, when they visit Solihull, is Solihull a good night out? [Dominic]Not bad at all. And Birmingham is a great city as well, because he must said when I left Birmingham to go to university at the age of 18, Birmingham was not the best city in the world. But over the last few decades, Birmingham has absolutely transformed as a city. They’ve kept all the best they’ve kept all the best bits and knocked down all the horrible bits and redeveloped it, so it’s great now. And Solihull’s good as well. [Jaz]Excellent. Dominic, thank you so much for your time today. I really enjoyed our chat. It was super clinical. I love these kinds of episodes. And we discussed real world scenarios about costings as well, which we said was really important to bear in mind. Very happy with that. Thanks so much for your time. [Dominic]No problem. Been an absolute pleasure. Jaz’s Outro:Well, there we have it, guys. Dr. Hassall is not a fan of cast posts, unlike Dr. Pasquale Venuti. So it’s nice to hear two different perspectives. You make up your own mind, listen to everyone and do what feels right to you. After all, I want to thank Dominic Hassall for coming on the show. If you like his education, check out his course. He did mention the Jaz10 code and I’ll put everything in the show notes so you can always learn more. I always like to promote what our guests do because they’re giving up their time to have a lovely conversation with us so we can all benefit. If you want to gain CPD for this chat, then you can answer four questions on the app to get it. You can even do a two-week free trial, rinse the CPD, and say goodbye. I don’t mind. As long as you’re learning, I’m happy. It’s on protrusive. app. So on your laptop, go to protrusive. app, or you can just download it on Android or iOS. It’s actually cheaper for you to get it on protrusive.app than on iOS, Android, and then you can use your login on iOS and Android as well. Basically, that’s the most cost-effective way to do it. You don’t pay any Apple fees. You don’t pay any Android fees, etc. The entire PDF transcript and the PDF show notes will be uploaded on the premium version of the app as well, alongside the CPD questions. And as ever, if you enjoy the show, please do consider giving some thumbs up, some stars, wherever you’re listening. I’d really appreciate that. I’ll catch you in the next episode.

In this podcast, Dr. Ajay Dhunna, a young dentist who graduated in 2018, shares valuable insights on excelling in your dental career. He emphasizes the importance of communication, attending conferences, and networking events. Dr. Dhunna and Jaz discuss strategies for managing stress and maintaining work-life balance. They also touch on topics like dental photography, career development, and reflection. Overall, it's an episode packed with practical tips for new dental graduates.

Are you a final year dental student or a recent graduate looking to kickstart your career as an associate dentist? In our latest episode we sat down with Dr. James Murray, a passionate foundation dentist who shares his recent insights and experiences on how to land a job as an associate dentist. Dr. Murray understands the challenges that come with transitioning from dental school to real world practice. He discusses the importance of building a strong portfolio and reflecting on your work to overcome imposter syndrome – embrace the learning process, seek feedback, and use every situation as an opportunity for growth. But what’s the best way to showcase your skills and make a lasting impression on potential employers? Dr. Murray reveals his secret weapon: an online portfolio accompanied by a thoughtful cover email. In this episode we also delve into tips for approaching dental practices that align with your values and interests. Struggle with taking clinical photos? Don’t worry, we’ve got you covered! Dr. Murray and Jaz provide helpful advice for improving your photography skills. So, if you’re ready to take the next step towards a fulfilling career, tune in to our podcast and unlock the secrets to securing your dream job! Access premium clinical videos by Jaz and gain CPD for Podcast episodes via the Protrusive.app https://youtu.be/AVREWCa8VN0 Watch IC041 on Youtube Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode: 03:14 Dr. James Murray04:02 Dental school experience06:22 Imposter syndrome08:02 Curriculum vitae09:09 Covering emails11:01 Do the research11:30 Portfolios14:14 Having the right attitude19:37 How to make your portfolio20:45 Photography in dentistry23:52 Photography tips and tricks26:30 Resources for photography27:56 Advice to new graduates31:22 Just-in-time learning If you enjoyed this episode, you may also like Young Dentist Thrival Guide – First Few Years. Click below for full episode transcript: Jaz's Introduction: This episode is one of two being published this week, all about the topic of career development, your first few years after qualifying, making an awesome CV and portfolio, and the most important things you should focus on as a new graduate. So think of this as a new graduate week, two episodes this week. [Jaz]This episode is aimed at any student, any newly qualified dentist. Or someone who’s just ready for a career change, i.e. either you’re applying for your first ever role as an associate dentist perhaps or you’ve been stuck somewhere for a while and you want to broaden your horizons and elevate your dentistry and so now you need to start thinking about a portfolio. Back in the day dentists would hire other dentists by a handshake. Then things evolved into curriculum vitaes or CVs. Of course, there’s always a place for a cover letter in an email, for example, to complement your CV, but nowadays it’s all about the PORTFOLIO. Portfolios are a great way to show that you are a caring, reflective practitioner, and they really help you to stand out against the competition. I’m joined by a newly qualified dentist, James Murray. Who’s going to give us a guide about what it takes to make a decent portfolio. Not because he’s the most amazing portfolio in the world, but he’s been in this space. He’s been thinking about this a lot because he’s in exactly the right stage of his career, newly qualified and has been very proactively. I’ve been very impressed with young man, very proactively building his portfolio, which helped him to get his associate position. Hello Protruserati, I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. This is an interference cast, which is like a non-clinical interruption. The themes covered in this episode are the portfolio, but everything that goes into the portfolio, what kind of stuff should you put inside there? What kind of photography should we be taking? And lots of photography tips in here. And it gives you a good insight into the challenges of being a newly qualified dentist. One thing we do talk about in this episode is COMMUNITY. And if you want to join a community, we have one on Facebook called the Protrusive Dental Community or on the app, protrusive.app. Once you’re a Protrusive member, you can access our secret telegram group. Let’s join the main episode with James and I’ll catch you in the outro. Main Episode:James Murray, welcome to the Protrusive Dental Podcast. How are you, my friend? [James]Yeah, really good. Had quite a quiet day today. A little bit of exercise. A little bit of work, a little bit of preparation for the podcast actually does just making sure making sure I can get all of my experience portfolios and deliver it in a way that, as you say, it’s quite tangible. [Jaz]Amazing. I love the use of the word. I appreciate it. Well, I could have got someone on, James, who was 15 years qualified. Right. But the problem here is the problem with that, James, is that when you get someone who’s 15 years qualified and we start talking about CVs and portfolios, they’re like, what are you talking about? I haven’t had to make one for like 12 years. Right. So they’re completely out of the loop. So who better than someone who’s like really, really thought about it? Because when you’re in the position where you’re just out of dental school. And you’re in your training year and then you’re having to have almost like a pressure to think about the next step and then you’re thinking about it and then nowadays with the world of social media, we’re seeing where everyone else is up to. We’re thinking, okay, I’ve got to get ahead of the curve and therefore, there used to be a back in the day, there weren’t no CVs necessary. You just shake hands on it. Then CVs became a thing in dentistry. Then it became two pages and more then the cover letters. Then now we’re going to talk about is the portfolios. Now, before we dive deep into that, James, just tell our good friends, our listeners a little bit about yourself in terms of where you qualified and what got you interested to talk about this kind of topic, which I’m sure is going to be very useful to anyone who’s thinking about applying for a job. [James]Yeah, so currently a foundation dentist. I’m working up north in the Newcastle region at the moment. Currently I’ve been applied specifically if you know the area, and yeah, graduated in Newcastle Uni in 2022 and always had a keen interest in restorative dentistry and actually delivering just the best care and the best quality of care that I can. And once I graduated, I found out quite quickly that one of the ways to do that was through taking photos and developing a portfolio, reflecting on my work. So that’s how I sort of came about trying to focus my work and focus this year on developing myself. [Jaz]Yeah, well, James, every time I have a fresh graduate on the show, I like to, if you don’t mind, I just like to ask about the current state of affairs of dental school in terms of totals, right? When I say totals, like how many procedures do you get done now? Right? So famously certain dental schools during my time, this was 10 years ago, would qualify with very few extractions. That was like a thing. I’m not going to say the name of the dental school. That was very low on extractions. It’s not mine. It’s not yours either. So don’t worry. But certain dental schools have the requirements of just doing six canals or something like that before you can qualify, et cetera, et cetera. Now, you we’re kind of part of the COVID year, but I’m thinking the COVID was kind of like, didn’t disrupt your clinical so much because your clinical was probably more towards 2021, 2022, but you can correct me. What were the totals and requirements like, and how much experience do you think you got or didn’t get? [James]Specific numbers. I would- [Jaz] Rough guide. [James]Rough guide. I would probably say there was about 70 extractions, 50, 60 fillings, and maybe four crowns, four endos. So, to be perfectly honest, going out of dental school, I didn’t feel like I had the most experience, and my third year, which was the COVID year, was disrupted. Currently in dental school, the look of the draw with patients, if you get a patient where they have absolutely loads, they have no time commitments, and you can call them in when you have a cancellation, that’s great. But for me, I didn’t until about end of fourth year, middle of fourth year, start of fifth year, really. So getting those numbers was a big stress. [Jaz]Huge. And the issue is, even when I was qualifying, I think I must have done like 12 crowns. And even then that was that kind of average, I think it wasn’t that much. And one thing I remember actually, James, is being really stressed or anxious about even qualifying first few years is, and tell me if you can relate to this, is breaking contact, i.e. if you’re doing crown prep and the interproximals try and break it without touching the adjacent tooth, distal of the upper molar, that was extremely stressful. It took me years to not have an escalated heart rate when I was doing that bit. Now, when you speak to experienced dentists, like, what are you talking about? Cause they forget, right? Is that still a thing? Do you have that as well? [James]Oh, I have that. I would say on every procedure, no matter how simple it is. Even this year, you can do every procedure you can in an hour and a half, do that in 20 minutes. And there is that imposter syndrome in your FD year and in dental school. There’s always going to be someone better than you, someone quicker. I worry on a daily basis thinking, is there a dentist who could do this job better than me? And the way that I’ve tried to reframe that, is by taking my photos taking my developing my portfolio and actually asking for advice from these dentists rather than being fearful or jealous or anxious about what they might think of the procedure that I’ve done. And I think that really helped set me up on the right path. [Jaz]Yeah. And any student listening, really, really key advice there. And I would say it’s extremely steep learning curve when you’re at dental school. And even just, especially in the year, last year that you’ve had basically in the big bad world, trying to do a lot of things still for the first time and first few times. And the advice I want to give to you, James is not even advice, the reflection I want to pass on to you is I admire the fact that you feel nerves. I admire the fact that you worry because, the dentist I’ve seen in my career so far that I’ve worked with who were same level of experience with me or less, whatever, that didn’t have the fear. They were reckless and they just didn’t care about the patient. It’s very few, thankfully very few. Right. So what you’re saying is, I think it’s completely normal and just shows that you are caring and you want to the best possible. So that will serve you well. Keep that up. That’s amazing. So let’s go into portfolios, which is the main thing. And the first question I want to ask you is CVs, cover letters, portfolios, 2023. What kind of stuff are you and your cohort of colleagues preparing? What do all these things look like as a snapshot for your generation? [James]So I think their previous thoughts were to write a CV, write down all your postgraduate qualifications. Write down all of your experience and things you’ve done outside of dentistry as well. However, coming out of FD and my cohort have very little postgraduate training. So when it came to it, I was very resistant to do a CV to be perfectly honest. I felt like it was a waste of time because the first thing is what would it actually achieve? And then highlight to the principal that I haven’t done those qualifications. And the second thing is that would it make me stand out? And the answer to both of those was NO. So the two things that I currently do or did do when I was applying for jobs was write a cover and email. And at the end of that cover and email, have a small link to my online portfolio that the practice principal could quite easily access. And that’s just how I’ve done it and there’s no right or wrong way to do that, that’s what I’m currently doing at the moment. [Jaz]And just to help someone maybe in your position in years from now, what kind of, some people get confused, I don’t know what to include in the cover letter. Can you give us a flavor of what, because you’ve thought about this a lot, you’ve done it a few times now. What kind of thing do you think is important to include in a cover letter? And is this to a cold practice, i.e., you don’t know the principal there, you don’t know anyone there, you’re just like, okay, you like this look of the practice, or was it a warm practice? [James]So, I think you can apply the same principles to every cover email, depending on whether you’ve had a recommendation to go there, whether you’ve seen it as an advert on Facebook. I don’t think that matters. The key principles to me in a cover letter, especially from the perspective of a foundation dentist, is willingness for mentorship, willingness to learn. And I think being humble and being open about where your weaknesses are as well. So just to really give you a flavor of a few of those things and how that might look in a cover and email. I think the first thing would be one of the phrases that I use is, I’m just a foundation dentist and although I may not have the postgraduate qualifications and experiences that you may require. I do have the willingness to learn and the willingness to develop. And I would say that’s definitely something that I would include in my cover and email. I think having a look at the website. But yeah, having a look at the website before you apply for the job. So that you know what the practice principal can offer you. But also the practice principal is the right type of person for you? Does he have the same interest and if you do share interest highlight that on the cover and email so I would say that That’s definitely one of the things that I would include. [Jaz]Well, I’m hoping that the Protruserati are cut above the average, right? And they’re very intelligent people. But now and again, we get colleagues who may send an email that reads a bit like this. Dear Principal, there’s no personal touch. You should know who the… They should know their name, right? Little basic things. And when I look at, I get lots of emails and stuff from people who want podcast. Like, Dear Host, or whatever. Dear Host of Protrusive. Piss off, right? Come on. There needs to be some sort of personal touch to it, right? So, that’s just basics, but I guess that is to, that is a hook for them to be like, okay, this seems like a genuine person. Let me now look at the portfolio. And I do think that the portfolio really is where you get to shine. Not necessarily because you’re an awesome dentist and you got all this cases, but a reflection, which we’ll come to. So. What did you use to build a portfolio? And what does a portfolio look like? How many pages is it? I mean, I’ve seen some portfolios because people email me their portfolios to check and whatnot. Please don’t see this as a license. Everyone to email me your portfolios. I’m already swamped, but to see what some of the ones I saw absolutely brilliant, but what they were is they were almost brochures, like 28 pages. I mean, very luxurious, very fancy. Does it have to be that way? Give us a flavor of that. [James]Well, I can only speak from my experience and currently I’ve only seen my own portfolio. My portfolio is currently 12 cases long. I’m a foundation dentist as well. So my cases that I’m presenting are not complex. They’re a simple adhesive onlay. They’re a direct composite, they’re a distal composite. I have a wide variety of things that I planned at the start of the year that I wanted to include. And I think when compiling a portfolio, you have to be asking yourself the question, what do I want to show the practice principal in this case? Is it a new matrix technique that you’ve learned? Is it the anatomy used following the Style Italiano Anatomy Guide? Is it improvement from one case to another? So, actually in my case, and I think it’s case 3 and 4, in mine that I’ve compiled, showing the improvement of my anatomy on a premolar. Something that I really struggled with, and it’s not the hardest thing to do. And I just printed off the Style Italiano guides and reflected upon that. I think it doesn’t matter how many cases a portfolio has. For me, it’s just about having a portfolio. It shows the practice principal willingness to learn. Willingness to develop. And I think ultimately it shows that you’re caring for your patient. [Jaz]I think that the best principles that I know, most forward thinking, they have been often the ones that hire young blood with less experience because what they do is they hire for attitude, right? And really you just need to be good enough. You don’t need to be like, at your stage, you don’t need to be like all this singing, dancing, doing veneers and stuff. It’s unlikely. It’s just dangerous, I’d say, right? You need to show that you’re a safe practitioner. And make your attitude shine across and that attitude comes from the reflection. Just like you said, I think a really great way to do it is here’s a premolar from the start of my year. Here’s a premolar from six months later. Here are the areas I focused on and I was so pleased that I managed to do it. I’ve got a little bit more to do, obviously. I’m not the finished product. But what you get with me is someone who keeps trying and wanting to do the best I can. And maybe a couple of radiographs showing the nice seal that you can make as well. Might add some good value. And I think if a principal sees that, they say, yeah, this person, A, tries B, reflects and tries to improve and C, they’re good enough. Their clinical dentistry is good enough. Now I want to invite them to interview to see if I like this person or not. What do you think to that? Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low? Let it grow or leave it high and let them cry. Listen, what are these interferences even interfering with? Is it safe to lengthen teeth? How much can I raise my patient’s bite? How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the DAHL technique and all my wear case? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics? How and why do you check for fremitus? What on earth is a custom incisal guide table? How do you use a leaf gauge? Do you always need to use a face bow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the f*** is centric relation? Occlusion is coming. One does not simply just open the bite. May the force of mitigation be with you. If you want to do a deep dive 30 plus hours into occlusion online, just like in this format, but actually individual videos, lessons that are five minutes long, 20 minutes long, a few odd half an hour lessons, and lots of clinical videos and case walkthroughs, then check out occlusion.online. It’s Occlusion Basics and Beyond online course with me and Mahmoud. If you are looking to take the next step in learning occlusion, that’s going to make your restorative dentistry predictable. [James]Yeah, there was one thing that a practice principal actually said to me that really stood out. They said that skills can be learned, but your attitude is very difficult to change. So if you’re going in with the attitude that as a foundation dentist going into associate year, you are brilliant, you can do your composite veneers, you know your anatomy, you can do your root canals in 30 minutes, for example. I think it’s just unrealistic and it shows that you’ve got the wrong attitudes because there’s always someone better than you and there’s always something you can learn from that person. And I don’t think any practice principal wants a dentist who isn’t willing to take advice and suggestions because it’s just a recipe for disaster. Well, that’s definitely what I’ve found anyway. [Jaz]Agreed. And the hard skills dentistry, as a long career, it can all be learned, but a big thing that principals think about when they’re hiring is, will this individual fit into my team? Will my patients like this individual? Do I want to see this individual every single day? Do I want to conversate with them? Will they get along with my nurses? Because all it takes, right, is one bad apple to completely ruin the taste of the entire practice. I’ve seen it done, usually it could be a new nurse, it could be a new dentist, whatever, and completely mess the dynamic of the practice. So yes, they want someone who’s good enough and that’s what your portfolio shows. When they see you at the interview, they look in the eye and and you show your human side. That’s what’s going to show them that, you know what, this person is a nice, caring individual. They’re enthusiastic. It’s good to have a pulse, right? It’s good to have some enthusiasm. And they think, yeah, this person is going to fit into my team. [James]I would completely agree with that. And I think it’s really important, not only for the practice principal to know that you’re a good fit for them, but that you’re a good fit for that practice. And making sure that your ethos really matches that they’re willing to invest in materials. They’re willing to invest in matrix bands, clamps, to give the best to their patients. And if that’s not the case, I think in my position, I would have been considering whether I’m the right person for there, and whether I can provide the best dentistry that I can to my patients. And I think that’s always something really important to have in mind. [Jaz]What did you use, James, to actually make the portfolio? Like, do you use Keynote, use, Google Docs? Just give us a flavor. Some people like, technology. They, it’s a hurdle for them. Just give us a flavor of what you used. [James]Yeah. So I actually asked for advice from a few dentists who are on Instagram. I chatted with dentists like Chris O’Connor, ones that I really respected. And the advice that they gave me was a website called canva.com. It’s a really simple software to use. You can drag and drop your images. You can reorder your boxes. It has lovely set templates. I don’t think it particularly matters what template you use, how it looks. You can do it however you want. But what I would say is that just choose a software that you feel comfortable with using. But I do find Canva really useful. [Jaz]Agreed. Canva is an absolutely brilliant tool. We use it for Protrusive as well. Thumbnails, artwork, that kind of stuff. It is fantastic and doesn’t have to be all this really, really pretty thing. It just needs to make it clear and easy to read and easy to follow for the person who’s reading it. And I mean, in terms of populating it with the photos, here’s an interesting one for you. Like a lot of dentists I know still don’t take photos, they go through their career that without taking photos. Obviously no one wants to read a portfolio as an essay like, Hey, I wanted a composite and I thought I actually well, and I produced a good result without any photos. That’s BS, right? So, what kind of photos are you taking? Are you taking intraorals? Are you taking DSLR? And tell us about your journey into photography. [James]So journey into photography, I had absolutely no. journey to start with. I started never being able to use a camera, getting all photographer in Newcastle University, take all my photos, my final spaces. But when I started, we had a brilliant study day and it was recommending and while just chatting about the sentence and the best thing that I did and the best thing that I can advise for any foundation dentist would be to buy their own camera and the settings get changed on your practice one in your foundation year, the settings got changed. The batteries on charge, the memory cards full photos get lost what was getting needed. [Jaz]And when you need it and when you need the camera, it’s in use or you can’t find it. And what it is when you’re ready to take a photo, it has to be there ready set up and ready to go. You never own a camera in dental practice, in a case, you don’t have to, if you have to actually assemble your lens to the body every time you use a camera, it’s not going to work beyond one day of your practicing career. So great advice there, James. Have it or have your own one. Have it ready to use. [James]Yeah, and that would actually say, well, I plan on a Sunday, all of my patient that I have. I look through my diary for the week and I think especially it’s important as a foundation dentist to maybe do a little bit of research before seeing that patient. You haven’t done a fiber post before, but ultimately I use it to identify those patients where I’ve got a little bit of type. I’ve booked out that hour and a half or that hour for a nice composite. And I know my camera’s going to be settled. I know my accessories. I bought the Focus Flex accessory kit from Minesh Patel’s website just with a little buccal mirror to take my intraoral shot for the camera. And I know you mentioned what photos do I actually take? The photos I primarily take are completely dependent on what I’m trying to highlight in my portfolio. So if I’m trying to highlight a matrix technique or it’s a posterior, I’ll be using the buccal mirror and I’ll be taking an in the mouth before shot, photo with rubber damp, photo with the cavity prepared, a fill in. So the photo with the filling under rubber dam and then the photo in the mouth without rubber dam and that’s my treatment sequence. Now if I wanted to highlight something else, maybe it’s a new wedging technique that might be something that I want to take a photo of and highlight in my portfolio in addition and some of my cases have two photos. Some of them have ten and it doesn’t matter. [Jaz]Agreed. And when you started to take photos, I think one advice I give to everyone is make sure whichever nurse is supporting you, you just get them in on it. Hey I’m a dentist who likes to take photos and therefore, let’s make sure the mirrors are warm to prevent-, prevent them steaming up, have some retractors. Like you said, so, so important, dentists have cameras and then they like have these horrible rubber, not rubber, the plastic retractors which don’t allow that from the mirror to go in so you can’t take an occlusal one. So you need one that she’s going to work in that sense. Tell us about your occlusal photos nine months ago and your occlusal photos now. [James]All my occlusal photos are not insistent Jaz. Previously they would have been steamy They would have been over or underexposed, so too light or too dark. They would miss off the tooth that I was trying to highlight. But ultimately there’s a few things that I found really useful. I think having some light already on the mirror from your overhead dental lamps really useful. And four handed dentistry, as he said. Working with the nurse. My nurse always has the 3 in 1 tip. Blowing air on the mirror so it never steams up. And to be perfectly honest, photography is all about experimentation. It’s all about trial and error, seeing what work, what doesn’t. Position of the patient, it starts to become second nature. And the more photos you take, there’ll be an exponential improvement in the photography. And that’s sort of, well that’s my experience of it. [Jaz]You hit the nail on the head. Photos are something that you just need to keep going even though your first six months of photos will be absolutely garbage. 90% of them will be absolute garbage, but it’s okay because you’re learning. And then eventually it’s muscle memory. It becomes so easy. I can take all my photos with just me. I don’t even need a nurse anymore. I can do the whole series without a nurse. But that took time for me to do. And one thing that Minesh Patel talks about, which I echo as well, is getting a really light setup that you can hold it in one hand. If you can do that, then it makes things very achievable and you can actually hold the other, the mirror in your own hand, get more control over that. And just keep taking, even though you’re rubbish, keep taking, keep taking, you’re going to improve over time. And then when you’ll find, when you’ve nailed your settings, then it’s just rinse and repeat. So if you’re someone who has been afraid to venture into photography, please do it. And if you’re struggling with occlusals, I do have a, I made a YouTube video like three years ago, four years ago. It’s on there about just occlusals because I find that’s a really tricky one. That a lot of people struggle with and of course you mentioned the buccal mirror was like that long, thin one, really good to take quadrant photos. So super important to have all this kit. Tell us James about any resources for photography that you recommend. [James]Yeah. So I think one resource for photography that I really recommend is the photography for dentist page and also the Two Dentists YouTube channel. [Jaz]Shout out to those guys. [James]I think both of those two things that I used and the photography The Dentist Page gave me an idea of the camera setup, the settings to use, and gave me some confidence on taking those first intraoral photos. And the two dentists also provided me with that, and I thought both of those were really useful. [Jaz]Two dentists, photography of a dentist page. I’m also going to add there’s a course called futurelearn.com which is a good simple course to do as well. That’s how I started. Gosh, that was like 10, 11 years ago. And also, on Instagram, dentist.camera. My friend Alessandro, he posts really good stuff from basics to more advanced stuff as well with photography. So, I’m glad to have shared those resources. Thank you. Those were the main questions I wanted to ask James in terms of portfolio building. But I just want to give you the mic, my friend. You’ve had a really, you told me before we started recording, you’ve had a really intense year. And I remember my first year at dental school was constantly learning every single minute something new, right? And every day I’m learning something new. When you’re a DF1, you’re learning whether it’s patient management skills, people management skills in terms of working as a team. You don’t know what you don’t know. There’s so much in perio, there’s so much in tooth replacement, so much in prosthodontics that we just don’t know because we just haven’t been exposed yet. Right? So what advice would you want to give a to your former self when you started the year? And then, to everyone else who will be joining your footsteps in the coming months. [James]I think there’s two things. I think in terms of the fear, the doubt, that imposter syndrome. Just understand that that is completely normal. That you are going to feel like you’re not as good as the other dentists in the practice. Because ultimately in terms of skill set, you know, and the faster that you understand that the more content that you’ll be. And one of the things that we were chatting about just before the podcast started was about reframing that into what can I learn from the people I work with. And my advice would be take photos, even when the work is dreadful, even when the work you’re not proud of, it’s an open contact. But if you don’t photograph that, and take that to your practice principal or your educational supervisor. How are they going to be able to give you advice? And if you can visually show them where you went wrong. They’ve done so many more courses, have so many more patient experiences with that. That they can completely guide you. So that would be two pieces of advice for those. And use your colleagues around you. Use them for experience because you can use every single situation as a learning experience. [Jaz]Well said. Every master was once a disaster and no matter what you see, you don’t see the journey. You don’t see everyone’s journey. You just see the beautiful stuff they’re posting out now. But 15 years ago, it wasn’t the way. Dentistry is a tough gig. But it’s so rewarding, and it is an expression of art. So my big thing now is trying to promote dentistry as art because I’m trying to think, what is it that’s going to make everyone have a fulfilling and happy career? And the more we can be artistic, the more it doesn’t necessarily mean cosmetic dentistry. You can be artistic with the surgery. You can be artistic in every way. Even the way you communicate with a patient can become an art. Embrace that art and see the beauty in it. And I don’t want anyone to bury their head in the sand and ignore the negativity. Have a awareness of it. But if you focus in on the negativity, it’s a bit like those slalom skiers. If they’re constantly focusing on avoiding the trees or the obstacles, whatever, they’re going to hit it. But if they’re focusing on the clear path. then they’re more likely to make it. James, thanks so much for giving up your time and enthusiasm to help the next generation of dentists. I think it’s going to help them to get a portfolio. I think it’ll give them the kick up the butt they need to just do it, right? Just main thing is just do it. And if you’re lucky enough to have listened to this episode as a student or at the beginning of your DF1, then do everything James said. Get that camera and ask your colleagues for advice. And we live in a time now where it’s never been a better time to a dentist who wants to learn. It’s never been a better time to be a dentist who wants to learn because learning opportunities are everywhere. And the problem we’re having now is that there’s too much, it’s too much noise. There’s too much stuff on YouTube. There’s too many podcast episodes of mine. There’s too many Instagram stuff, right? There’s too much. And so what you end up doing is you end up drowning your life trying to learn this, learn that, learn that. I’m a big advocate. I don’t know if you heard me say this James before of just in time learning. Yeah. If you know, you know, like, I love what you do on Sundays. That’s amazing, man. That’s really good. And if on Sunday, you’ve seen that, Hey, on Thursday, I’ve got my first resin bonded bridge. I haven’t done one of those in ages, or it’s been a long while. Since I’ve done it. Then make the flavor of that week. You know what? I’m going to revise the bonding protocol. I’m going to, do we have panavia? What cement do we have in the practice? I’m going to think about the prep design if required. I’m going to think about my lab. I’m going to think about which photos I’m going to take rather than just revising extraction techniques that week when actually you haven’t singled that out as something you need to focus on. So a big fan of just in time learning. So I was going to add that in. James, thank you so much, my friend. [James]Nope. Thank you very much, Jaz. I appreciate it. Jaz’s Outro:Well, there we have it, guys. Some top tips on how to make the best portfolio, how to put your best foot forward. These are essential nowadays. And if you have a CV, if you have a cover letter and a portfolio, I think you really stand a good chance to get that interview. And at that interview, you just show them your human side. You show them that you can fit into the team. And with that, I wish you all the best. Thanks for listening all the way to the end. I really hope you get the associate position that you deserve. If you enjoyed this episode, please do consider giving it a rating wherever you listen to it. Otherwise, I’ll catch you same time, same place next week.

[Trigger warning: this episode discusses topics related to mental health, depression, self-harm, alcohol abuse, and suicide.] Humans first, Dentists second. We will all have personal rough patches during our career – but how does this impact our work and our patients? A Protruserati shares his experiences of a toxic marriage, self harm and alcohol dependence – I am so grateful he anonymously shared his valuable insights and lessons for dentists seeking to prioritise their mental well-being. https://youtu.be/ZED_yS8v8sc Watch IC040 on Youtube Throughout the episode we touch on coping strategies, emphasising the value of exercise and physical activity for mental well-being. We also explore the guest speaker’s path to recovery from alcohol abuse, including their positive experience with the Allen Carr course, which aimed to change their perception of alcohol. We delve into their experiences with counselling and highlight the importance of being in the right mindset for therapy to be effective. In addition to this we touch on the HeartMath technique, a powerful self-regulation approach that our guest found beneficial in managing emotions and achieving a sense of calm. Below you can find links to these resources, including the ConfiDental helpline – an accessible and confidential listening service designed specifically for dental professionals. Allen Carr EasyWay – www.allencarr.com/easyway-stop-drinking/ HeartMath – www.heartmath.com ConfiDental – 0333 987 5158 Access premium clinical videos by Jaz and gain CPD for Podcast episodes via the Protrusive.app Need to Read it? Check out the Full Episode Transcript below! Highlights of the episode: 04:22 Our guest’s story12:32 HeartMath14:59 Poker face18:33 Going to work mentally unwell21:00 Leaving toxic environments27:38 Advice for those struggling31:34 Reaching out If you liked this episode, you should check out Toxic Work Cultures in Dentistry – Time for a Change? Click below for full episode transcript: Dr. Anonymous: I didn't enjoy going to work. I think, I always thought, I wasn't very well slept and I didn't have the energy and I had to put it on, and it was a lot of effort. So, yeah, I think it was, it was difficult for me. I didn't want to go to work. Jaz’s Introduction:Do you remember practicing dentistry when you had a cold or you weren’t feeling well? Well, you must remember how difficult that was, right? Because dentistry is such a stressful thing. We’re dealing with people’s emotions all day long. We’re dealing with intricate procedures in small places, so when you’re not feeling your best. Man, that adds even more to an already stressful profession. There are various times in our careers that we will enter a rough patch. Now, before I give you examples of this, I want to give a warning for this episode that this episode does contain a lot of triggers that might upset some listeners. We tackled some very dark themes in this podcast episode. My guest, who is a dental professional, discusses episodes of self-harm, divorce, excessive alcohol intake. And these are the kind of themes that we’ll be discussing under the broader umbrella of difficult, rough patches that we may face as professionals. And the reason why you made this episode today is to help anyone who’s listening who may be. Going through a rough patch and of course will. It’s inevitable. We will all go through rough patches. We’ll all have an argument one day. We won’t be feeling our best every day. I don’t feel my best every day, despite what you guys might think, right? I have bad patches. Everyone has bad patches. This is life and we need the resilience to navigate through those bad patches. A lot of talk nowadays, more and more, which is brilliant about mental health, looking after your mental health. So I’m hoping this episode will help someone, will inspire someone. If it helps just one person, it is worth it. Because of the nature of this episode, the audio episode will be on Spotify and Apple and Google Podcasts. The video version will be only available on the premium version of the app, so that’s protrusive.app on the website or on the iOS and Android store, because I didn’t want this stuff to go on YouTube because of how sensitive things are that we discuss. If you’re new to the podcast, wow, you’ve picked a different one to join us, but something that’s so, so important, right? For our wellbeing and so that we can serve our patients the best. Like when you are not feeling your best, whether that’s emotionally, physically, in any way, you are not serving your patients the best way. So that’s why I think this episode is important. I’m ever grateful to my anonymous guest who joined us today. He revealed so much about himself and gave so much, or just to help someone else, just to help another dental professional who may be going through a rough patch. So let’s lend him our ears. And be sympathetic not only to this colleague that we had on, but to anyone in our profession going through a rough patch. Hello, Protruserati. I’m Jaz Gulati and I’ll catch you in the outro. Hello, Protruserati. Today I’m joined by a really good soul, someone who’s volunteered their time to help you guys because this is a very sensitive topic we’re talking about today. This episode is for anyone who has ever faced adversity or will face adversity. And this could be anything. This could be extreme stress, this could be depression, this could be miscarriage. That’s a very stressful thing. This could be something that, anything that basically means that your frame of mind may be altered, and then maybe when you’re seeing patients and you’ve lost your mojo, and this could happen to all of us in our careers at some points, right? So it’s about this kind of what lessons we can learn from a colleague who’s joined us today, who went through a difficult patch himself basically and very kindly will share his story. So Anonymous Dentist, thanks for making time for this. Obviously your voice, this is not your real voice, the voice we’ve edited it, manipulated it in a significant way so you’re not identifiable, but just where do you want to start with the story that you’re going to share today with us? [Dr. Anonymous]Oh, thanks. Thanks for having me, Jaz. Yeah, I think it’s a difficult one. It’s one of those things that most of us, at some point in our life we experience and the difficult experiences that do make us stronger in a way. So when you look back on, it’s a hard time your life. But when you come out the other end, you come out stronger. So it’s anyone who has, who is going through anything difficult, just know that it’s better when you come out of it. [Jaz]So what happened to you? [Dr. Anonymous] For me, I think it was, I was in a pretty bad relationship and I think when you have a long, bad relationship, it takes two people to make it fail. And I was one part of that but for me it was pretty bad. I felt in very, very dark places, on and on. And I remember at the time I was working long hours, at the hospital, looking after patients in A&E to a pretty bad episode of self-harm, where I ended up in A&E myself in one of the bays, next to the, before I used to look after that kinda thing. [Jaz]This is while you were in maxillofacial. [Dr. Anonymous]Yeah. [Jaz]So basically what you’re trying to say is you had an episode of self harm yourself. [Dr. Anonymous]Yeah. [Jaz]Whilst you were also under that role basically? [Dr. Anonymous]Yeah, so I think basically I did maxfax for about three years and it’s already a stressful job. You’ve got a stressful relationship at home and then sometimes arguments and things can escalate. So this was at home after a long shift. And I got in warm and I had an argument with my partner and things got out of hand and I basically self-harmed and it was pretty bad. I couldn’t walk for eight weeks. I was in a boot, in a wheelchair, in a cru tch. And eventually I got out. And the worst part of it is that this happened in the beginning of the second year of that relationship. And I carried on in that relationship or another six years after that. So it was a very dark time in my life. [Jaz]Does that mean you were off? I mean, I’m so sorry to hear that and what you went through, but wow. I mean, I’m just absorbing all that. That’s a big take. Again, we didn’t talk about the exactly your story. So this is all new to me as well. So firstly, I’m so sorry. But then did you have to like, take some time off work? How are work? Did you tell work what happened and how did they support you? One thing I want to know is when someone, you work for a trust that you work, for example, and you tell your trust this happened, and I’ll assume that you did tell them what happened or maybe not. You can tell me. Were they supportive? That’s what I want to know the most. [Dr. Anonymous]Yeah, I think it varies on the trust and on your consultant.And I had a really, really good relationship with the oral surgeon and even the maxfax consultant in that trust. So I think initially I was worried about what to tell them because my main worry is this a significant mental health issue where they’re obliged to report in GDC or not. And so I wasn’t sure what to tell them, but I had a really, really good relationship with the oral surgeon, and I just told him what happened. Actually first I did lie to him and then he’s like, ‘why don’t you hop off and let’s get some fresh air?’ And I was like, ‘I can’t, I’m in a boot.’ And he’s like, ‘no, don’t worry. I’ll, I’ll bring a wheelchair’. So he called wheelchair. And he took me out of the hospital to get some fresh air. It was really good. And we were talking and yeah, I kinda broke down with him and I was honest and he was very, very supportive. And one of the nicest people I’ve ever met. [Jaz]Yeah, it sounds like it already, it sounds like this oral surgeon. He suspected something and he wanted to take you in a safe place to discuss that and that is something to be said about the character of this person, right. [Dr. Anonymous]It is, it is. Honestly, it is amazing. I think he’s one of those people that I know when we run on clinic and we get a referral for TMJ issues, he’ll run an hour late with a patient. Cause he wants to know like their whole background history about any stress. And he’s such a natural at getting stories outta people or people who they not to be stressed for things like that. And they’ll tell you, they’re telling their life history and everything. He’s a very good soul. [Jaz]Mm-hmm. [Dr. Anonymous]And, he still works in that place. So- [Jaz]So thanks to him, thanks to this individual. You managed to get some support, like you had a couple months off and there was like no, like blame culture or No like you didn’t, obviously it’s tragic what you’re going through at the time, but I’m hoping they were supporting you get through that rough patch. [Dr. Anonymous]They did, absolutely. And I didn’t take the full two months off. So I think I took, I was in hospital for four days under the plastic surgeons, and then I got home and I took another week off after that and they told me to take the four, eight weeks off, but I was like, I can’t.I need to come back to work. So I went back to work in a wheelchair. The best part about it is I got one of the disabled parking spots right outside the hospital. [Jaz]Silver linings always silver linings. [Dr. Anonymous]Yeah. And so I did clinics, cause I could do that on a wheelchair and sitting down and stuff. And, I did a lot of admin stuff. I held a bleep. And then after the wheelchair I think I was in the wheelchair for another two weeks. And then I managed to get on crutches. And then with crutches, I went about doing everything I could. I went to A&E and all the rest of it. So it was yeah. [Jaz]Was that the first, like, time in your relationship? Was that the first time? If you don’t want me asking, was that first time you relationship that things had escalated this bad or other moments? Not necessarily in terms of outcome, in terms of self harm, but in terms of how you felt and whatnot, and how it might have might affect your mood and your ability to be your best when you go into work, you know? Was that the first time? [Dr. Anonymous]No. No. I mean, I think with things like this it’s usually towards the end of a really long string of smaller episodes, and then this is like a major event. So, yeah, it does start with small issues and it does get bigger and bigger. Yeah. It’s lots of arguments, lots of, we never quite obviously physical into physical type, but it was emotionally very, very draining. And it does take a toll on your mental health. [Jaz]Did you get any help as a couple? Well, I mean, I’m hoping you’re going to tell me that this is the direction you went in terms of therapy, counseling, that kind of stuff. Is that something that you explored? [Dr. Anonymous]So after this event, after the self-harm, we did and I don’t think it helped. I think most people need to be on board for it to work. That’s the first thing. The second thing is when you go to a counselor and you talk about the issues in relationship, there is a fine line where you talking about the problems. And not being looked at as tried to bring the counselor over, the therapist over to your point of view. So, say things for them to agree with you and think that’s, exactly. And I think that’s the problem that we had in counseling where, one of us didn’t think counselors or therapist could help. And then when we did go and we’re talking about the issues that are bringing us there, you get the blame of thinking, you’re just saying the most awful things to try and win over the counselor and make me look like the bad person. So we tried, I think about four or five sessions that, it wasn’t really for us. [Jaz]But what if someone listening to this right now is going through a similar thing in a relationship? And would you at least suggest that they give it a go cause it didn’t work for you, but maybe- [Dr. Anonymous]Absolutely. [Jaz]Do you think it’s worth giving a go, right? [Dr. Anonymous]Yeah, absolutely. And I think if not, definitely try everything you can. And if the couples doesn’t work for you, then make sure you get some help for yourselves. At the very least, at least you’re looking after yourself, then. [Jaz]Well, tell us that how far into this journey that you went through, did you eventually get individual help for yourself? [Dr. Anonymous]So I did at the end, so this was year two. The relationship continued for another six years after that. We were in a relationship for seven years in total, and then once it all officially ended, then I got some help and yeah. I went to Malta, they had this juice, juice fast retreat thing going on over there. So I just went to that. And over there, there was a yoga instructor and he is just amazing. Like I didn’t realize I was having help, but me and him would go for walks and yoga and stuff. And then at the end of it, he told me that he’s an instructor in something called HeartMath-ing. I can go through that later on if you want. [Jaz]Yeah, just tell us what it is. You sparked our interest now. [Dr. Anonymous]Yeah. So HeartMath, it just blew my mind, basically. It’s a very, so we did yoga. That’s one thing that helps. And then HeartMath is a breathing exercise. Now I know everybody goes on about breathing exercises and how they work and how it affects your mental health. You don’t really know because you hear about them, you read about them. But I think it’s until you see the effects and the benefits that you realize how important it is. So the way he did it with me is, he goes onto his login for HeartMath and then he has an ear probe that connects to your phone or your laptop or something, monitor your heartbeat. So he just connected it to me and we started talking about just random things. For five minutes we’re just having a chat and we were moving from topic to topic, talking about films or books or sports activities, just random things. And then after the five minutes, he said, why don’t we just do some breathing exercise for five minutes? And he said, breathing through your heart, imagine there’s a hole in your heart and you’re breathing in through that, breathe in for five seconds, and then breathe out through the same hole in your heart, just send love to everybody out there in the world to people that you like, to people that you don’t like and breathe out for seven seconds and we’ll do that continuously. And yeah, just think about the breathing in and the breathing out. And that’s it. We did that for another five seconds and then we looked at the heart rate on the monitor and the results were amazing. The first five minutes were just so chaotic. Your heart rate is just fluctuating up and down and there’s no rhythm. And you look at the last five minutes there’s just this constant level, no heart rate. And yeah, there’s a whole spectrum and it’s a beautiful, beautiful thing. And for anybody out there who’s interested, just go Instagram and type meyouyoga, and you’ll find him. He’s an Italian guy called Sal Puma, and he’s one of the mentors on HeartMath. He’s just, it’s amazing. [Jaz]I mean, the advice there basically is that, whatever difficult time you may going through, and sometimes it is self-help and looking after yourself. So important. Now, that can come in many forms and you are a case study. You’re like at n=1 like this, work for you. And so, and then we like recommendations, right? We go by people, you know, trust and stuff. And so after hearing what you went through and how you try to overcome it, and then listening to that, that might inspire someone to be like, you know what, I’m going to look after myself a little bit more and try a therapy, that sounds amazing to me. Now to get back to more about how we can help people who may be in a rough patch. If you look back at your time now and the journey and the ups and downs and stuff, do you wish that you would’ve seeked help sooner? Because it looks like you waited till the end to seek help. Imagine someone has had an argument with their spouse this morning and they’re going to work now, they’re listening to this podcast episode. They’ve had a argument with their spouse. They’re not in a good place. And I mean, you’ve been there, we’ve all been there to some degree, right? And you’re not in a good place and you can’t be your best. And sometimes you need to give everything to your patient. When you are doing in even a Class II, Class II’s are not easy. They’re tricky, right? They’re fiddly. They need a lot of tension, dedication to get a lovely contact point. So how can you give your best to that individual who’s put their trust in you when you are not in the right frame of mind? So, what kind of, how would you feel and how did it affect your work in that regard in terms of your enjoyment and fulfillment from work? And then do you wish you would’ve got help sooner? So it’s a two part question. [Dr. Anonymous]Yeah. So I think with this sort of situation, there’s two aspects to it so one is I think I was also having quite a bit of alcohol at the time and I think that has its own problems and you’ve also got the mental issues. And I think it’s a bit like the way I felt was what, I don’t know how to describe it. Maybe, I don’t know, in university or you go shopping and you have like, seven Tesco bags in each hand, and they’re really, really heavy. And you walk back to your apartment, 10 minutes and your fingers are really sore and you put bags down and you feel that sense of relief that you’re just like, oh. And I see, like, it becomes like a chronic situation where you feel like you’re carrying something on your shoulder and it becomes normal for you, and you don’t realize it’s there anymore, but it’s always there. Or like a really tight pair of shoes that you’re wearing. They’re really uncomfortable, but eventually you get used to it, but you don’t realize it until you take the pair of shoes out. Then you realize that you’ve been carrying this for a while. And I think that’s the first stress. And the second stress is the lack of sleep. I think when you’re having drinks or you’re in a bad relationship, you’re not sleeping well, it is difficult and you just bring your A game whenever you get, and you know, you just try your best. You’re not a hundred percent. You don’t realize it at the time. But when you go to work, nobody can tell. These are people who, people like this are very outgoing and social, and everybody around you thinks that, oh, he’s such a fun-loving guy. He’s such a great guy. [Jaz]So, you’re saying basically that you had a really good poker face. You’re at work, you’re receptionist. They couldn’t tell these internal struggles that you’re going through. [Dr. Anonymous]Yeah, absolutely. Absolutely. [Jaz]And that itself is a burden that is difficult, you know? [Dr. Anonymous]Yeah. [Jaz]It’s like you’re living, I guess false life is a term we could use. You’re living you’re living a lie in the way that you can’t express yourself at work. And you are at work so many hours a day, but you’re trying to distract yourself. You’re trying to be your normal self, you’re trying to be you’re happy-go-lucky person that you are rather than it’s stuck in this difficult time you’re trying to get out of that, but that itself plays a burden on you. But I guess you have to put that face on to give your best to your profession. Is that how you felt? Maybe? [Dr. Anonymous]Yeah. Absolutely. Absolutely. And I mean, who knows about, you’re right about patient care and stuff. I think it’s difficult to look at it retrospectively and see that if you could have done a better job, but when you’re out at the other end and you feel the way you do and you go to work and you know that you’ve got real energy and passion, then you realize that there is something more than you can give. [Jaz]Was dentistry for you like you know what? I need to get out of home. I need to get out of this, and I’d rather go to work and I love dentistry. Or were you like, you know what? I feel crap. Like you know when you got a cold and you have to like a really nasty cold and you have to go into work with a nasty cold, and it’s just not pleasant. You’re trying to get through the day and it’s just it is what it is. Where did you lie in that mindset of going to work? [Dr. Anonymous]I was in the second group. I was definitely in the second. I didn’t enjoy going to work. I think, I thought I wasn’t very well slept and I didn’t have the energy and I had to put it on, and it was a lot of effort. So, yeah, I think it was difficult for me. I didn’t want to go to work. [Jaz]I mean, dentistry’s so, so stressful already, right? Where that is and the most stressful. The best bits about a job is a people person. It’s a people job basically. You’re seeing people all the time, you’re building connections, trust, that kind of stuff. That’s the best part, but it’s also the most taxing part that you have to deal with emotions. You have to consent people, you have to make decisions, decision making, both in your treatment plan and what the patient will accept and actually decision making in a micro level, like which wedge to select, to which matrix band, to which type of prep, constant decision making. So it’s a very taxing profession that itself was adding stress and burden to you and I know obviously those of you listening, watching, you don’t know who I’m speaking to, but this individual, is kind of like me. We’re course junkies. We like to learn and stuff. And so how did you cope with juggling, trying to be the best that you can at your work and learning more and managing this issue that you had internal at home and stuff? Did you take more holidays? Did you try and take more breaks? I mean, how did you cope? [Dr. Anonymous]I think the courses were amazing. I think that definitely helps. You’re right, I did go lot different courses. I did a lot of learning, I did lot of shadowing, and those were the best days of the whole year. I think, so that definitely helps. Sport is definitely something that does help as well. So any form of exercise and movement brings you in a good place. And I think whenever you go for a run or something, you hate the idea of it before, but when you finish it, you do realize that you’re full of energy stuff. So, that is good. But otherwise it is difficult. It’s there. There’s no easy way out of it. I think the only thing to learn is that it’s better to not be in a relationship than to be in a bad one. It was one of those things that was difficult. Those seven years were the most difficult years of my life. It was difficult to juggle. [Jaz]I spoke to Sandy who came on. He talked about a toxic workplace and how eventually he said he had to draw the line. He had to leave that work and find a new associate position. And he’s thriving now. He’s loving it. Without giving much away about you. I see you now and we had a conversation on the phone and you are really, you’re back to yourself now. You’re back to your happy go lucky, smiling self. And you’re in a good place now. But getting there can be tricky. And so what was the final trigger, if you like, or final thing that made you make a very bold and brave mutual decision? I hope in terms of, okay, we need to end it now so that we can heal because you decided, it sounds like what you’re saying is that, from what I’m reading between the lines, you’re kind of saying that. You left it too late. You wish you’d left much earlier. But it’s a bit like when you’ve been at practice for 10 years and now it’s becoming toxic. But because your patients will know, your receptionist know, to have to leave a job and find a new associate position, for example, I’m just drawing comparison. It’s a tough decision to make. Like, you know what I’m handing my notice in? It’s a big deal for a lot of people, your kids might be at local school. It’s the fear of the unknown. What were you thinking when you finally sort of decided that this was it? [Dr. Anonymous]So, yeah, I’ll tell you exactly what it was. Because I remember that very, very clearly. I think, so I’ll tell you a little bit about my relationship with alcohol and then it’ll lead on quite well to this. So I’m somebody who started drinking quite late in life and when I was at university, I probably only have a drink three or four times a year. And it was the same in vt, practice, nights out or Christmas time or something like that. When I got into a relationship and I think you talked about this before about lifestyle creep and you get a bit more money and you start to afford things a bit better and then you’ve got company to enjoy it with, and you start to drink a bit. So then you drink maybe twice a month and you start to drink once a week and then you drink twice a week and it goes on, and then you’re having a glass of wine every night and you think it’s normal glass of wine that’s fine every night with your food. And then you have a couple of glasses a night, you know? Then, so I was at a stage where I’m having about two glasses of wine every night after work. And I listened to a podcast by Brad Thornton. He’s a dentist. I don’t know if you know him. [Jaz]Yes. Yeah, of course. Yeah. Brad, shout out to Brad. [Dr. Anonymous]Yeah. And he interviewed somebody who unfortunately has now passed away, but he interviewed somebody who had a pretty difficult relationship with alcohol himself. And he was one to two bottles of spirit a day, every day. And he eventually tried to commit suicide. And it was a pretty, pretty harrowing podcast, when you listen to it. And the thing that hit me is that he said in his podcast that he didn’t just start drinking one to two spirit, bottles of spirits a day straight away, five years before that, it was two glasses of wine at night. And I’m like, I’m having two glasses of wine a night. I’m five years away from attempted suicide, you know? And I was like, okay, something has to change over here. And, it also reminds me of another analogy you said in one your podcast about the frog in boiling water, right? When the water is cold, it gets a bit warmer and warmer and before you realize it, reassuring in boiling water and you saw get out anymore. So I think that was point, which I was like, okay, I think this needs to end. The things that roll you back are you’re in your early thirties, you don’t have a chance of getting another relationship inside your family and it’s all very scary, but then you realize it’s better than the alternative, which is and things will just escalate and get worse. So that’s the point at which I was like, I think this needs to end. And I joined Quit Drinking Course by Allen Carr. It was called, The Easy Way Course, and I think a lot of some celebrities have been on it for either smoking or for alcohol. And it was amazing. It was really, really good. It was really, really good. And I think basically, drinking provides you with some benefit. Firstly. Secondly, I think the main thing that’ll make somebody stop or not stop, sorry, is that they think that it’s very, very difficult to stop and do you like it’s impossible. Or I’d have to go through delirium treatments for three weeks and spread it out in a room or something like that. Whereas I think in this course, it’s just a one day course. You do realize that it’s not that difficult because everything that you know about alcohol is an illusion, and it’s wrong. And I think as soon as you see it, it’s like, have you seen some of those pictures where they tell you to look at something and you can’t see it and you’re staring at the picture and they’re like, you can see the word in that jumbled up spheres of black and white over there, but you can’t see it. And then they tell you to squint your eyes and move dark and then all of a sudden you can see it. And then once you see it, you can’t unsee it. You can’t look at that picture again and and not see it. And it’s a bit like that. [Jaz]And I think it’s a bit like finding MB2. When you first find MB2 okay, then you can’t stop finding it. I want to make it dental in some way. [Dr. Anonymous]Oh, exactly. So, yeah, I think that’s it. So one of the illusions we talk about it taste, and when you think about alcohol, high end people talk about how this nutty ale tastes so good, or cheeky sutan or I don’t know, peat and brine and all these different flavors and coke and things like that. But actually it’s all, it’s all the marketing. Think about the first time you ever tried alcohol. I know for me it was horrendous. It tasted disgusting. I couldn’t even swallow it. And I think that’s how- [Jaz]You have to pretend. It’s like beer. You have to pretend to like beer long enough until you actually like it. [Dr. Anonymous]Exactly. Exactly. Exactly. And the first time you, I know the first time I tried it, it was disgusting, but there’s always somebody there to tell you, don’t worry, it’s an acquired taste. And over time you’ll learn to like it. And that’s it. But the reality is that, you need a lack of taste to be able to tolerate it. and that’s how it’s o over time your taste buds just forget how bad it is. And the reality is a poison a half, half a of alcohol neat will kill you. And I think, back in the day when we were hunter gatherers, that’s how we knew our taste buds knew what to take and what not taken, alcohol is one of those things. If we did try it back then, we would’ve probably just started out and not had it again. So they talk about a lot of different illusions on the course, and I think once you start to see it for what it is, the flavors all come from sugar of some sort. And that’s what really keeps it going. [Jaz]That’s very useful perspective on anyone. Alcoholism is a serious thing that we need to spread a good message about in terms of overcoming it. So if I was to say to you with after everything you’ve been through, and like for those of you who don’t know, the colleague I’m speaking to today, fantastic dentist, really proactive, like, you could tell this dentist proactive because they sought to go on this Allen Carr course, they sought to go on this retreat. You have to be in, we actually met on a course once, so I won’t say which course it was, whatever. But you’re a very proactive dentist. But even you found it very difficult to end a toxic relationship. Early enough and that’s, it’s a testament to how difficult and how tough these things are. So whether someone is going through depression or any other bad moment in their life, tough patch. Rough patch. Okay. What are the top 2, 3, 4, 5, and as many bits of advice if you have, if I just give them microphone and say, listen, any of my colleagues who were in a bad place consider doing the following. What kind of advice can we leave the Protruserati with to, no matter what they’re going through right now, how can we help them get their mojo back so that they can serve their family, serve their patients well, and live life to the fullest? [Dr. Anonymous]I think the first thing is just realize where you are in life. Cause I think, just look at your relationship with any sort of drug, whether it’s smoking, alcohol, food, and just see if it’s a healthy relationship or not. And I think if you don’t realize that it’s not a healthy relationship. Then you carry on in that situation for quite some time. Secondly, I think if you do realize that you’re not having a healthy relationship with something like alcohol, don’t think that you’re alone and don’t be embarrassed about it. When I went on this quit drinking course with Allen Car, it was full of high achievers and our brain when we think about an alcoholic, we think about somebody on the road, homeless person, with a can of beer. But actually I think there’s a lot of high achievers, doctors, lawyers, dentists for sure, who are very, very successful, who have a bad relationship with alcohol. So if you think you have one, don’t be embarrassed about it because there are a lot of other people in the same boat as you. You just go and get help. And there’s many ways of stopping drinking. This is the one that I use. Thirdly, I didn’t use ConfiDental, but I’ve heard lots of good things about it. So, when the mental dental group started and I saw what they were doing, fantastic stuff. So at the very least, if you need some help, you can go through that route. And then I would strongly suggest to go on a retreat somewhere. So, sometimes you go on a holiday and you come back and you got to go to work the day exhausted. And you just, you feel like you need a holiday from your holiday. I think maybe once or twice a year if you can just go on a holiday where you’re not having food and drink and all the rest of it. Just spend maybe four or five days at a retreat where you have some yoga, some very healthy food. Or in this case it was juice. And, honestly, the energy you get out it, you think that, oh, you’re only having full glasses of juice per day. You must be starving, you’re full, full of energy. And you come back and I was ready to start the next chapter of my life. And, when you have that good energy, you spread that good energy and you get that good energy back. And I went from a position to your thinking that this is it. I’m not going to have a family ever. And within one year I was engaged, within two years, I’m in a very very happy place and we’re hoping to start a family, soon. Yeah, so I think once you’ve got some good energy to give out there, and the third thing is always help somebody in some way. And that gives you immense mojo but also juju and also you feel so good. It’s just very, very good energy. The alcohol course I went on they said that the 12th step if you were to go to AA I don’t know, but if you were to go AA, apparently the 12th step is to try and help somebody else get out of the crap. And yeah, it’s just very, very helpful to yourself and your soul, when you help somebody else. [Jaz]Amazing. Now, I mean, thank you so much for sharing not only your story. I know we’re going to keep everything anonymous, but still, like, I really appreciate you sharing some tough times because, I once recorded with, a colleague and she talked about adversity in New Zealand. You might have listened to that episode. And she was absolutely brilliant. And I had a dentist message me saying that everything that she was saying about how she felt and how distress that she felt work, she was one of the podcast listeners one of the Protruserati, she was driving and she started flooding in tears. And she had to literally, like, I think she said, she had to like park her car somewhere, or it might have been on the motorway. She had to go in the sideline basically. But like I’m sure that even if this helps one person. And it’ll help more if it just helps one person that we’ve done something today. And if we’re in a good place now, then remember that nothing ever is promised. We will always face adversity in life. Life will always come with challenges and some of the lessons and themes that you’ve covered today for us in terms of looking after yourself, getting help, going on in some sort of retreat or something. Even the HeartMath you said? [Dr. Anonymous]Yep. HeartMath. [Jaz]Something to consider and how can you help yourself? It’s a bit like when you are on an airplane, they always say, do your seatbelt first before you do someone else’s. Do your life mask first, air mask, whatever, before you do someone else’s. It’s that you have to look, if you look after yourself, then only then can you serve your family, can you serve your children, can you serve your patients. And so that’s really important. So if any lesson is today, if you found these themes hard hitting, do you feel affected by these, then please don’t. The worst thing you do is just be like, okay, click on the next episode. Reach out to someone or some organization. It could be ConfiDental, it could be a retreat, it could be someone to help you through a tough time that’s relevant to you. I think that’d be the most important action you could take. [Dr. Anonymous]Absolutely, a hundred percent. How they say in dentistry, always invest in yourself. Clinically, you always talk about how you go on courses, invest in yourself clinically, but mentally as well. Absolutely. 100%. Take the time twice a year and do something that’s going to give, put you in a good mental state. Jaz’s Outro:Amazing. Well, there we have it guys, because inevitably we’ll all go through a rough patch, and I hope this episode will help you. It might find you at a time where you are not in a rough patch, but hopefully listening to someone else’s story will just make you aware of colleagues around us that may seem that everything’s going okay, but under the surface there are cracks. And if you notice those cracks, please send them this episode, or send them to ConfiDental or send them to any of the resources that our colleague shared with us today. And so what I’m going to do is I’m putting the show notes that HeartMath, that Allen Car course for helping him overcome the alcohol addiction and any other resources I can find to help anyone going through a rough patch in their lives. If this episode was meaningful, if it helped you in any way, I would love for you to leave a review on wherever you listen to your podcast. And I appreciate you listening all the way to the end. I know it was a tough conversation at times because the themes covered, but we can’t just shy away from these themes, it can’t just all be composite veneers the whole time, right? We need to discuss these real-world themes. So, thank you so much once again for listening to Protrusive and I’ll catch you in the next one. Once again, thank you to the guest that came on, who gave up his time and shared his vulnerable story. I respect you so, so much my friend.